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LIBRARY OF THE
UNIVERSITY OF ILLINOIS
AT URBANA-CHAMPAIGN
AC
6 O/
eS OO
.
4 “
it
MIND AND ITS DISORDERS
MIND
AND ITS DISORDERS
A TEXT-BOOK FOR STUDENTS AND
PRACTITIONERS OF MEDICINE
BY
Vimo LOW Deki MED bO RCP.
PHYSICIAN non lexrat DISEASES TO ST. THOMAS’S HOSPITAL
LECTURER ON MENTAL DISEASES TO ST. THOMAS’S HOSPITAL MEDICAL SCHOOL
LATE EXAMINER IN PSYCHOLOGY AND MENTAL DISEASE TO THE UNIVERSITY OF LONDON
HONORARY TREASURER OF THE BRITISH PSYCHOLOGICAL SOCIETY,
AND OF THE BRITISH PSYCHO-ANALYTICAL SOCIETY
LATE RESIDENT PHYSICIAN AND MEDICAL SUPERINTENDENT OF
BETHLEM ROYAL HOSPITAL
FIFTH EDITION
WITH ILLUSTRATIONS
PHILADELPHIA
P. BLAKISTON’S SON & CO.
1926
First Edition
Second Edition
Third Edition
Fourth Edition
Fifth Edition
Printed in England
November, 1908
August, 1912
August, 1919
September, 1921
September,, 1926
ay Ke
9 eRe. (n
hl »wO
<Q sco
L)® / ( Ce OQ
ieee nee ho shir FIP RH EDIRION
For the present edition the work has been thoroughly revised
throughout. The following are, perhaps, the chief changes.
Under the heading of Treatment of General Paralysis in the fourth
edition I gave a critical digest of the manifold methods of intra-
thecal medication. As these methods have all been nowadays
replaced by two more recent and successful ones—viz., the try-
parsamide and the malarial treatment—I have described these
methods in some detail to the exclusion of the above critical
digest.
A chapter on Encephalitis lethargica has been included. .
I am again indebted to Mr. W. H. Gattie, K.C., for revising
the chapter on the Insane and the Law, and to Dr. Eric Graham
Howe, of Bethlem Royal Hospital, for his scrupulously careful
and conscientious revision of the proof-sheets. I also wish to
express my gratitude to my wife for making herself responsible
for the Index, which will therefore be found much more reliable
than that in the fourth edition.
W. H. B. STODDART.
Harcourt HOousg, °
CAVENDISH SQUARE, W.1.
July, 1926.
oO
rt
Ww Vv
J
-
@#09975
PREFACE TO THE FOURTH EDITION
Tue flattering reception accorded to the last edition having
exhausted the stock much earlier than was anticipated it has not
been possible to make, in the general scheme of this manual,
certain radical changes contemplated in the desire to orientate
my readers among the enormous mass of contemporary research
in this field, mainly by Professor Freud and his followers.
One of the many results of this new knowledge is that the
classification of mental disorders is temporarily in a state of
flux, and I have again effected some rearrangement of the
chapters in Part III. to show how our classification stands at the
moment.
My views regarding neurasthenia require that this malady be
classified as a psychoneurosis, and not as a neurosis.. Since going
to press it has become obvious to me that exophthalmic goitre is
also a psychoneurosis, and not a true neurosis. Exophthalmic
goitre is really a variety of anxiety hysteria, and should be
described under that heading. It follows that the only true
neurosis is the anxiety neurosis.
The researches of Ferenczi, Pierce Clark, and others, into the
mysteries of epilepsy have demonstrated this disease to be a
psychosis and it is now described under that heading. More-
over, we have to recognize that alcoholism and drug habits are
psychoses, differing from those maladies caused by the excessive
use, or rather abuse, of alcohol or drugs. These are intoxications;
therefore alcoholism and the alcoholic insanities are described in
different parts of the volume. Indeed, Chapter XV. would have
been more in its proper place as Chapter XIII.
Vii
Viil PREFACE TO THE FOURTH EDITION
In view of the fact that there is a thread of psycho-analysis
running right through the book, the short chapter assigned to
this subject has been entirely rewritten.
When the manual was first published, my endeavour was to
induce the reader to think neurologically of mental processes,
normal and morbid, and to study them from a neurological point
of view. Since that time, however, owing to the psychological
researches of Freud, and previously Janet and others, it has been
found that we gain a clearer insight into mental processes when
we approach them from a purely psychological standpoint; but,
although I am a loyal disciple of Professor Freud, I am not one
of those who would therefore abandon other methods of research
into mental processes. I am sure that Freud himself would
adopt the same attitude; for in spite of his triumph in this branch
of medicine, he is too great a man to deride other methods of
investigation. ©
The neurological and psycho-analytical points of view are
so different that any attempt to describe both in the same
volume, much more to correlate them, is rather liable to present
an almost unavoidably futuristic picture. Mental and physical
factors are even more intimately related than is commonly -
supposed. Physiological processes and physical diseases almost
invariably have their mental concomitants or sequele; and
mental processes, both normal and morbid, may originate gross
organic changes. We are only just beginning to learn that the
endocrines are a most important factor in neurosis, psycho-
neurosis and psychosis, and the time is not far distant when it
may be possible for a manual of psychiatry to be written from
an endocrinologist’s point of view without opposing the psycho-
analytical trend of thought in the very least. Not yet, however,
has this aspect of the subject been evolved sufficiently for me to
refer to it in the text, except here and there, and quite super-
ficially.
I wish to express my best thanks to Dr. Clement Lovell,
PREFACE TO THE FOURTH EDITION 1X
Pathologist to Bethlem Royal Hospital, for preparing specimens
of the Gold-Sol reaction for the plates in Appendix B, and
passing them for press, to Dr. Brushfield of the Fountain
Hospital for some new photographs for the chapter on Mental
Deficiency, and especially to Dr. John Rickman for his careful
and conscientious revision of the proof-sheets and for valuable
suggestions.
Weed. pb. STODDART,
Harcourt House,
CAVENDISH SQUARE, W. I,
July, 1921
We Ose le Fe NS:
Jeri kell Jk.
NORMAL PSYCHOLOGY.
CHAPTE Ral
INTRODUCTION.
Mentation. Psychological Methods. The Neuron Theory. Syn-
apses. Neurokyme. Scheme of the Nervous System. Con-
sciousness and Sensation. Unconscious Mentation - -
si Om Oe ae 0 al a
SENSATION.
Its Attributes and Modes. Unconscious Sensations - - -
CHAPTER III.
PERCEPTION AND IDEATION.
Their Similarities and Differences. Their Physical Basis. Space-
perception. Time-perception. Conception. Ideational Type.
Unconscious Percepts - - = - - -
CHAPTER IV.
ASSOCIATION OF IDEAS.
Compound Ideas. Associations by Similarity and Contiguity. Cog-
nition. Recognition. Memory and Forgetting. Imagination.
Judgment and Reasoning. Unconscious Associations - -
CHAPTER V.
APP ECT EON.
Tones of feeling. Emotions, Passions, Moods and Temperaments.
Their Physical Basis. Unconscious Emotion - - -
CHAPTER VI.
ACTION.
Reflex, Instinctive, Voluntary and Automatic. The Reaction Ex-
periment. Unconscious Action - . Z :
xi
13
30
47
54
65
xl CONTENTS
CHAPTER VII.
ATTENTION,
Its Laws and Varieties. Voluntary, Instinctive, Reflex and Auto-
matic Attention - = 4 . : 3
.
CHAPTER VIII.
FATIGUE, SLEEP AND DREAMS.
Muscular Fatigue. Contracture. Intellectual Fatigue. Sleep,
Dreams and Hypnosis - - - - -
CHAPTER IX.
THE SENTIMENTS:
Esthetic, Moral and Intellectual. Modes of Belief - - -
CHAPTER X.
LANGUAGE,
Gesture. Pantomime. Wordsas Symbols of Mentation - -
CHAPTER Al
LE EGO:
Its Development. The Super-Ego. Personal Differences. The
Unity of Mentation - - - ~ Es
PART II.
PSYCHOLOGY OF THE INSANE.
CHAPTER 1;
DISORDERS OF SENSATION.
Cutaneous Analgesia. Diminution of other Sense-modalities.
Hyperesthesia. Erroneous Localization. Hysterical Disturb-
ances of Sensation - : s . . =
CHAPTER II.
DISORDERS OF PERCEPTION.
Imperception. Ideational Inertia. Physical Basis of Imperception.
‘“Systematized Anesthesia.’? Hallucinations and _ Illusiors.
Their Physical Basis and Psychology. Synesthesize - -
CHAPTER III.
DISTURBANCES OF THE ASSOCIATION OF IDEAS.
Retardation and Acceleration. Disorders of the Normal Sequence of
Ideas. Disorders of Memory - - - ‘ :
PAGE
86
92
104
109
II2
118
124
140
CONTENTS
CHAPTER IV.
DISORDERS OF THE EMOTIONS.
Excess and Defect of Emotional Reaction - - - -
CHAPTER V.
ABNORMALITIES OF ACTION (DISORDERS OF
CONDUCT).
Apraxia.’ Disorders of the Instincts; their Rise and Fall. Erro-
neous Instincts. Disorders of Speech and Writing. Disorders
of Attention - - - - - - -
CHAPTER VI.
ERRONEOUS JUDGMENTS (DELUSIONS).
sane and Insane Delusions. Insight. Disorders of Sentiment.
Changed Personalities. Sex and Station. The Comprehen-
siveness of Mental Disorder - - - - -
CHAPTER VII.
PSYCHO-ANALYSIS.
The Unconscious. Complexes and Conflicts. Repression. Sub-
limations and _ Reactions. Psychosexual Development.
Technique. Free Association. Interpretation of Dreams.
Transference - - - - - - -
CHAPTER VIII.
ANOMALIES OF THE SEXUAL INSTINCT.
Masturbation. Sexual Inversion. Sadism and Masochism. The
Role of the Senses - = - ‘4 a ae
PAR L EL:
MEN PAL DISEASES:
CHAPTER I.
THE CAUSATION OF MENTAL DISORDER.
Endogenous and Exogenous Causes . - - -
CHAPTER II.
THE PHYSICAL STIGMATA OF DEGENERATION.
The Cranium. Atavistic Anomalies. The Pinna. The Palate,
The Jaw. The Limbs. General Abnormalities - .
xiii
PAGE
148
152
165
176
Ig!
198
ZEE
X1V CONTENTS
NEUROSIS.
CHAPIER sit;
PAGE
THE ANXIETY NEUROSIS 219
THE PSYCHONEUROSES.
CHAPTER IV.
NEURASTHENIA 224
CHAPTER V.
AY SLERTA:
Conversion Hysteria. Fixation Hysteria. Anxiety Hysteria.
Mental Characteristics. Hysterical Insanity. Exophthalmic
Goitre - - - - - - - - 230
CHAPTER VI.
THE OBSESSIONAL NEUROSIS:
Compulsive Thoughts, Fears and Impulses_~ - - = - 252
THE PSYCHOSES.
CHAPTER VII:
MANIACAL-DEPRESSIVE INSANITY (INTERMITTENT
AND PERIODIC PSYCHOSES).
Melancholia. Mania. Anergic Stupor. Terminal Dementia.
Psychopathology. - General Management - - - 260
CHAPTER VIII.
PARANOIA.
Eccentrics and Egocentrics. Communicated Insanity - - 304
CHAPTER IX.
DEMENTIA PRHACOX.
Its Obscure Pathology. Catalepsy and Catatonia. Simple
Dementia Precox. Hebephrenia. Katatonia. Dementia
Paranoides - - r : : Z eas
CHAPTER X.
PARAPHRENIA.
Paraphrenia Systematica, Expansiva, Confabulans and Phantastica
Paraphrenia ab hallucinatione - - - - 343
CONTENTS XV
CHAPTER XI.
PRIER PSY AND EPILEPTIC INSANITY.
PAGE
The Epileptic Character. Epileptic Convulsions and their ‘“‘ Equiva-
lents.”’ Epileptic Dementia - - - - - 349
CHAPTE ROXIE
ALCOHOLISM - - = 372
CHAPTER XIII:
SOME OTHER DRUG HABITS.
Morphinism. Cocainism. Chloralism. Paraldehydism. Chronic
Sulphonal Poisoning. Cannabis Indica Poisoning. Belladonna
and Atropine Poisoning. EtherInebriety. Plumbism - - 376
TOXIC INSANITY.
CHAPTER XIV.
ACUTE CONFUSIONAL INSANITY.
Mental Exhaustion and Intoxication. Synaptic Rebuff - - 388
CHAPTER XV.
ALCOHOLIC INSANITIES.
Etiology. Physiological and Pathological Inebriation. Delirium
Tremens. The Polyneuritic Psychosis. Subacute Alcoholic
Insanity. Chronic Hallucinatory Insanity. Alcoholic Para-
noia. Alcoholic Dementia - - - - - 399
CHAPTER XVI.
MENTAL DISORDERS ASSOCIATED WITH PRIMARY
DISEASE OF THE ENDOCRINE ORGANS.
The Thyroid (Myxcedema and Cretinism). The Pituitary Body.
The Suprarenals. The Pineal. The Sex Glands - - 419
ORGANIC INSANITIES.
CHAPTER XVII.
GENERAL PARALYSIS (DEMENTIA PARALYTICA).
Clinical Varieties. Modern MethodsofTreatment. Morbid Anatomy 431
XV1 CONTENTS
CHAPTER XVIII.
MENTAL DISORDERS ASSOCIATED WITH COARSE
CEREBRAL LESIONS.
PAGE
Increased Intracranial Pressure. Cerebral Poisoning by Products
of Neural Disintegration. Focal Symptoms - - - 463
CHAPTER XIX.
ENCEPHALITIS LETHARGICA, EPIDEMIC ENCEPHALITIS
OR PLEEPY SICKNESS. - - : - - - 4068
CHAPTER AX.
CHRONIC CORTICAL ATROPHY.
Arteriopathic and Senile Dementias. Presbyophrenia. Alzheimer’s
Disease - = - 7 5 ss = 473
CHAPTER XXI.
MENTAL DISORDER ASSOCIATED WITH CERTAIN OTHER
NERVOUS MALADIES.
Chorea. Huntington’s Chorea. Paralysis Agitans - - - 484
CHAPTER XXII.
MENTAL DISORDERS OCCURRING IN ASSOCIATION WITH
VISCERAL DISEASE.
Prolonged Pain. Pulmonary and Cardiac Disease. Blood-Pressure,
Uremia. Diabetes. Gout - - - - - 488
CHAPTER XXIII.
IDIOCY AND IMBECILITY.
(AMENTIA OR MENTAL DEFICIENCY.)
Symptoms. Varieties and Degrees. Binet-Simon Tests - - 492
CHAPTER XXIV.
COMBINED INSANITIES - - 515
CHAPTER XXV.
MEIGNEGD JIN SAIN, Joyo) - - 518
CHAPTER XXVI.
SOME DISEASES TO WHICH THE INSANE ARE ESPECIALLY
TTAB LE,
Phthisis. Asylum Dysentery. Cutaneous Affections - - 521
CONTENTS . XVil
CHAPTER XXVII.
PAGE
CASE-TAKING - - - 532
CHAPTER XXVIII.
GENERAL TREATMENT.
Asylum and Single Case. Contraband. Bed. The Physician,
Occupation. Seclusion and Mechanical Restraint. Food and
Feeding. Hydrotherapy. Medicines. Prevention of Suicide:
Visits and Letters from Friends - - - - 539
CHAPTER XXIX.
THE INSANE. AND THE LAW.
The Board of Control. Establishments for the Insane. Reception
Orders and Certificates. Judicial Inquisition. Transfer.
Escapes. Legal Capacities and Responsibilities of the Insane.
Schedule Forms - - - - - - - 550
APPENDIX A.
METHODS OF STAINING THE NERVOUS SYSTEM - 575
APPENDIX B.
EXAMINATION OF THE CEREBRO-SPINAL FLUID - - 580
INDEX : : : . : : : - 586
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FIG, PAGE
I. Two NorMAL BETz CELLS : - Coloured Plate facing 5
2. A Motor CELL FROM THE PRECENTRAL GYRUS - : 6
3. SCHEME OF THE NERVOUS SYSTEM - - Plate facing 10
4. BLIND Spot DIAGRAM - - - = 5. 23
5. THE CEREBRAL CORTEX - - - - - eS 2
6-8. To ILLUSTRATE “‘ IDEATIONAL RIVALRY ”’ - - - 34
g-12. To ILLUSTRATE ‘‘ IDEATIONAL UNITY AND THE PERCEPTION
OF DEPTH” - - - - - - 35, 36
13-17. To ILLUSTRATE THE MUSCULAR ELEMENT IN VISUAL SPACE-
PERCEPTION - - a : 37, 38
18, 19. METRONOME DIAGRAMS (TIME-PERCEPTION) - - = 42
20. SLEEP CHART (AFTER E. W. SCRIPTURE) - ~ =e 07,
21. EXAMPLES OF ANALGESIA IN THE INSANE ~ - - 119
22. APRAXIC PSEUDOGRAPHIA - - . - - 160
23. APRAXIC IDEATIONAL INERTIA IN WRITING - - TOt,) LOZ
24. SENILE WRITING - ~ - - - - 163
25. INCIDENCE OF INSANITY - - - Plate facing 203
26. DEFORMITIES OF THE PINNA - - - a aa 213
27, 28. H@mMaToMA AURIS) - - - - “ - 214
29. Casts OF DEFORMED PALATES - - - Plate facing 215
30. SIMIAN THUMB OF A PATIENT SUFFERING FROM DEMENTIA
PRAECOX - - . - - - - 216
31. NoRMAL THUMBS, FLEXED TO SHOW THE INTERNAL ROTATION
OF THE TERMINAL PHALANGES ~ - - - 217
32. SIMIAN HAND OF A PATIENT SUFFERING FROM DEMENTIA
PRECOX - - - - - - ay,
33. PERIODIC INSANITY - - ~ - Plate facing 262
34. MELANCHOLIAC WRINKLING - - - . - 266
35, 30. MELANCHOLIAC HANDSHAKES - - - - 267
37. FACSIMILE OF TEST-TYPES USED IN THE INVESTIGATION OF
MELANCHOLIA - - - - Plate facing 268
38. SLEEP CHART IN MELANCHOLIA - - - eats,
39. AGITATED MELANCHOLIA - - . : a egy:
40. MELANCHOLIAC GAIT - - - - - wee 27
41. ACUTE MANIA - - - - - - - 284
42. ACUTE MANIA - - - ~ - . - 285
43. MANIACAL HANDSHAKE - - - - ~ - 286
44. ManiacAL HANDSHAKE - - = a a. Ly ~ 287
LIST OF ILLUSTRATIONS
. SLEEP CHART IN MANIA - - - . -
. HYPOTONIA IN ANERGIC STUPOR - - = =
. ANALGESIA IN A CASE OF TERMINAL DEMENTIA - -
. AGE-INCIDENCE OF DEMENTIA PR#COX - = =
. SIMIAN HANDS OF DEMENTIA PRACOX - - -
. DEMENTIA PR#COX: ERECTION OF THE HAIR - - -
. NORMAL MUSCLE CURVE - - - - -
. DEMENTIA PRHCOX CURVE - - -" - -
. DEMENTIA PR#HCOX: WRINKLED FOREHEAD - - -
. DEMENTIA PR#COX: FLEXIBILITAS CEREA . - -
. KATATONIAC ANTIC - - - - - -
57. DEMENTIA PR&cOX HANDSHAKES - . - -
. PSEUDOGRAPHIA - = = & - -
. HEBEPHRENIAC SECLUSIVENESS - - - - -
. DEMENTIA PRZCOX GROUP - : : A i
. IMMATURE BETZ CELLS IN DEMENTIA PRACOX
Coloured Plate facing
. ANALGESIA IN THE CASE OF ACUTE CONFUSIONAL INSANITY -
. PART OF A LETTER BY A WELL-EDUCATED PATIENT SUFFERING
FROM ACUTE CONFUSIONAL INSANITY - - -
. Betz CELL IN ASTATE oF AXONAL REACTION Coloured Plate facing
. WRITING IN SUBACUTE ALCOHOLIC INSANITY - . -
67. SPORADIC CRETIN - - - = é -
. LETTER BY A GENERAL PARALYTIC - - - -
. CORTICAL VESSEL OF A GENERAL PARALYTIC, SHOWING TYPICAL
PLASMA CELLS - = = ‘ > :
. GLIA OR SPIDER CELL FROM THE CEREBRAL CORTEX OF A GENERAL
PARALYTIC - = - 2 = ~
. SPIDER CELLS IN THE INNERMOST CORTICAL LAYER FROM A
CASE OF CHRONIC INSANITY - - - -
. FILM MADE FROM THE CEREBRO-SPINAL FLUID OF A GENERAL
PARALYTIC - - - Coloured Plate facing
. SENILE WRITING - = = S, s 2
. SENILE BRAIN - = . = a a
. GENETOUS IMBECILES (BROTHER AND SISTER) - - -
. HyDROCEPHALIC IMBECILE - = : 2 :
GROUP OF MONGOLIAN IMBECILES - : oe is
. MICROCEPHALIC IDIOT - - : x > be
. HYPERTROPHIC IMBECILE - ms 2 2 =
. EPILOIA - - = es “ * 3
. BINET-SIMON TEST: PAIRS OF LINES~ - = - =
‘iG ES - « A * of
“5 fy », « MiIssInc PARTS - a - A
» 5 tL OLDED (Paper - 3 4 E
» 5 eo CARD ws : - 4 x8
. PROLONGED BATH - = = z . -
. (a and b). Gotp-Sot REAcTION Coloured Plates following
PAGE
290
297
299
318
319
a21
321
322
322
325
327
329
pe
333
336
340
390
393
410
412
424
443
457
458
459
462
476
478
498
499
500
501
503
504
507
508
509
511
511
544
584
ERRATA
Page 303, first line, for “ paralysis,” read “psychoanalysis.”
Page 326, seven lines from bottom, for “cataleptic,” read
catatonic.”
66
xe
< x * 45
9 eae
SS Fn eet
peal pee
MIND AND ITS DISORDERS
Baul. I:
NORMAL PSYCHOLOGY.
CHAPTER I-
INTRODUCTION.
“ It ts even so—Nature is nowhere accustomed more openly to display her
secret mysteries than in cases where she shows traces of her workings apart
from the beaten path ; nor is there any better way to advance the proper practice
of medicine than to give our minds to the discovery of the usual law of Nature
by careful investigation of cases of raver forms of disease. For it has been
found, in almost all things, that what they contain of useful or applicable is
hardly perceived unless we are deprived of them, or they become deranged in
some way.’’—WILLIAM HARVEY.*
THE medical curriculum is so arranged that during the first two
or three years the student learns about the structure and func-
tions of the normal human body so as to prepare him for the
study of disease when he gets into the hospital wards or sub-
sequently into practice. There is, however, a curious and
remarkable omission in that he receives no instruction in psy-
chology or the study of the normal mind to prepare him for the
study of mental disorders which he will subsequently encounter
among his patients. It therefore falls to the lot of a treatise of
this nature to supply the omission by giving a short preliminary
exposition on normal psychology.
The study of the normal mind can be approached from many
aspects; one of these the student will have encountered in the
course of his ordinary medical studies—viz., psychological
physiology. This consists of the study of the central nervous
system in general, and of the brain in particular—its structure,
histology, and physiology, and all that is included under the
term “‘neurology’’. He will have learned something about
Loeb’s tropisms, Pavloff’s conditioned reflexes, and a relation-
ship between certain endocrine glands and the emotions. There
* Quoted from Sir Archibald E. Garrod’s “ Harveian Oration,” 1924,
I
2 MIND AND ITS DISORDERS
‘
is also “ physiological psychology’, which endeavours to reduce
specific mental processes to laboratory form and to examine
them by means of various ingenious types of apparatus. We
shall have to allude to this branch in further detail, because of
its utility for descriptive purposes. :
When, however, we come into practical relationship with the
minds of individuals in the world of reality—as, for example,
in the dealing with patients—we find that physiological psychology
does not help us very much; we therefore have to approach our
subject from yet another angle, and to study the mind #er se,
paying little or no regard to its physical basis or to physiological
principles. Leaving out of account the speculative psychology
of the last century, there are many other ways of investigating
the mind. We may, for example, approach it from an evolu-
tionary standpoint by examining the behaviour of animals and
endeavouring to arrive at some conclusion about what goes on
in their minds (animal psychology) ; or we can make observations
of normal human children in order to trace the way in which
the mind develops in a normal person (child psychology). Then
there is “applied psychology’’, or the study of the mind in
certain practical relationships—for example, educational psy-
chology, industrial psychology, including vocational psychology,
esthetic psychology, social psychology, and medical psychology,
which last is of the greatest importance to the readers of this
treatise. The titles explain themselves; but, in whichever
territory any particular psychologist may be working, he will
find it helpful to take an occasional peep over the wall to see
what his neighbours are doing.
Now it has just been hinted that normal psychology should
form a part of the medical curriculum in order to prepare the
student for the study of mental disorder; but in medical
psychology greater advances have been made by investigating
mentally afflicted patients than by exploring the psychology
of normal individuals. Indeed, psycho-analysis, which plays an
important rdle in medical psychology and will subsequently be
described, is a science which was entirely developed from the
study of such patients whose mentation deviated from the
normal.
There is nothing new in this principle. The paragraph at the
head of this chapter shows that it was recognized by the great
Harvey more than two centuries ago; yet, so long as physiology
remained a purely academic science, it was not of any great
value to clinical medicine. It is only in recent years, during
PHYSICAL BASIS OF MENTATION 3
which physiology has taken the facts of clinical medicine and
pathology into account, that it has been of service to clinical
medicine. This principle is also illustrated in other natural
sciences, é.g., in astronomy new stars have been revealed by
observing the deviation of other stars from their expected course;
in chemistry new elements have been detected in an analogous
way. Argon was discovered by noting that there were certain
discrepancies in the weights of the gases of the atmosphere.
There is, however, no necessity to labour the point; in all branches
of knowledge we learn about the normal by studying the ab-
normal. The discoveries having been made, the student of any
particular science is taught ordinary natural processes before
proceeding to those which are anomalous or unusual; but, for
reasons which will appear later, it is often found that it is better
_ for even beginners in medical psychology to learn about mental
mechanisms from the abnormal, every patient being a new
research de novo, and subsequently to ascertain to what extent
those mechanisms occur in a normal person.
Until the present century psychology suffered from too much
importance being attached to sensation, which was considered
_ to be the essential unit of mental experience, while affection was
regarded as a mysterious sort of side show, disturbing to sensa-
tion and perception. But when we come to think of it, what
determines a particular line of conduct is not any particular
sensation or percept, however complex it may be, but the affective
tone of pleasure or displeasure which accompanies it. This can
be observed even in the very lowest micro-organisms. The
amoeba, for example, moves towards a morsel of food, but away
from anything that is harmful to it. A plasmodium will move
towards a drop of water and ultimately immerse itself in it, but
move away from a drop of brine, thus exhibiting an elementary
form of affective tone or desire accompanying the crude sensa-
tions aroused by the water, brine, food etc. Loeb and his school
look upon human behaviour as a complex of similar tropisms,
and psycho-analytical investigation in man has shown the unit
of mental experience to bea wish. Of course, many of our wishes
are frustrated by external circumstances, or even by an opposing
wish in the mind of the same individual. Such thwarting of our
wishes is naturally disappointing; but, so long as the process is
conscious and recognized, it does little orno harm. In the course
of this volume, however, it will be shown that some of these
conflicting desires may be unrecognized and therefore uncon-
scious, and that they are then liable to give rise to all sorts of
4 MIND AND ITS DISORDERS
complications, sometimes mental disorder or even physical
disease.
On the other hand, physical disease may give rise to mental
disorder in all sorts of ways, either by its direct. effect on the
mind or by causing nutritional disturbance of or definite organic
changes in the brain. Throughout the ages a great deal of
discussion has taken place respecting the relationship between
the mind and the brain. To us as physicians it does not matter,
but to us as philosophers it may matter very much indeed.
Broadly speaking, there are two main schools of thought.
According to the first—the spiritwalistic—the material brain is
pervaded by an immaterial something, the mind or soul, which
is held responsible for all men’s thoughts and actions. The
adherents to this view are divided into two sub-classes: (a) Those
who regard the connection between body and soul as a Divine
arrangement (occasionalists or phenomenalistic parallelists) ; and
(6) those who regard the mind or soul as the principle of life and
thought (animists, Aristotelians, monists). According to the
second or interactionist school, the mind is regarded as a process
or function having its physical basis in the brain (epiphenomenal-
ism); mental and physical mechanisms proceed simultaneously
without having any direct relationship with one another (psycho-
physical parallelism), or perhaps a more accurate way of ex-
pressing this view would be to say that a certain causal relationship
is recognized, but that the nature of the relationship is not known.
In general, this is the view adopted throughout the present
manual, but an attempt is made here and there to demonstrate
the connection between various mental and physical processes,
and to correlate them so far as our present knowledge will
allow.
The medical student approaching the study of mental disease
for the first time will already have acquired some considerable
knowledge of general medicine and pathology. This he will find
essential for the comprehension of his new subject. It is also
important that he should have a sound knowledge of the anatomy
and physiology of the nervous system, and this he will have
acquired in the course of his ordinary medical studies. Recent
investigations would appear to show that in the near future a
knowledge of biochemistry and the physiology of the endocrine
glands is likely to play an important réle in the study of mental
disease. For the present it will be necessary to study the nervous
system from a fresh aspect, including the way in which it sub-
serves the function of mentation.
TRE LIRSARY
OF THE
WNIVERSITY OF ILLINOIS
Fic. 1.—I wo NorRMAL BETZ CELLs.
Showing the arrangement of the Nissl bodies (chromato-
plasm—tigroid substance)—in large cubes or oval spindles
which extend into the dendrites but not into the axon (%) or
the eminence from which this arises. The nucleus is situated
centrally and is clear. (X600.) [Negative kindly lent by
Dr. John Turner of Brentwood Asylum. }
To face p. 5
THE NEURON 5
We may now regard as accepted that the nervous system
consists of myriads of isolated* neurons, each of which has
potential connections with other neurons, by which nervous
impulses may be transmitted from one neuron to another. In-
going nervous impulses are conveyed from the peripheral sense-
organs to the central nervous system in general and, so far as we
as students of insanity are concerned, to the cerebral cortex in
particular; while outgoing nervous impulses are conveyed from
the central nervous system in general and, so far as we as students
of insanity are concerned, from the cerebral cortex in particular
to the muscles of the head, trunk and limbs.
A neuron or nerve-cell is, then, to be regarded as a mechanism
for the transmission of nervous impulse from one part of the
organism to another, mostly to and from the cerebral cortex,
which is itself nothing more or less than a mass of neurons.
Each neuron consists of a cell-body or perikaryon, an axis-
cylinder or axon, and one or more protoplasmic processes called
dendrons. A nervous impulse enters by way of one of the
dendrons and passes through the cell-body to the axon, whence
it is transmitted to the dendron of another neuron.
If the cell-body be stained with methylene blue (Nissl’s
method), it is found to contain in its middle a large unstained
nucleus, in whose centre is a deeply stained nucleolus (sometimes
two). When stained in this way (vide Appendix A), it may be
observed, moreover, that the substance of the cell-body consists
of an unstained fibrillar or reticular matrix (achromatoplasm)
enclosing a large number of roughly triangular stained granules
(chromatoplasm, tigroid substance or Nissl bodies). The fibrils
of the achromatoplasm can frequently be traced through the
cell-body from the dendrons to the axon, or from one dendron to
another; hence it is inferred that the function of this substance
is to convey nervous impulses from one part of the neuron to
another, and it has for this reason been also named the kineto-
plasm. And from the fact that the chromatoplasm gradually
disappears as the result of fatigue, it is inferred that this sub-
stance serves the function of nutriment to the cell. It has
accordingly received the alternative name of trophoplasm.
The protoplasmic processes or dendrons are, as a rule, branched
and beset with large numbers of minute twigs or thorns, like so
many pinheads protruding at right angles to these processes.
It has been demonstrated by Lugaro that these twigs, which
* The fact that protoplasmic continuity between neurons occurs occasion-
ally, but rarely, is of purely academic interest.
6 MIND AND ITS DISORDERS
are called gemmules, are more or less amoeboid, since they are
protruded during sleep and retracted during activity.* Demoor,
however, held the opposite view. Little differentiation of struc-
ture of the dendrons can be determined under the microscope.
The axis-eylinders or axons are longitudinally fibrillated and,
so far as they remain within the confines of the grey matter,
Fic. 2.—A Motor CELL FROM THE PRECENTRAL Gyrus (SEMI-
DIAGRAMMATIC).
a, Axon with collaterals; b, dendron showing gemmules; c, moniliform
(degenerate) dendron from which the gemmules have disappeared.
unprotected; but as soon as they reach the white matter, they
are enclosed within myelin sheaths, which appear to be the con-
ductors of electrical currents. In their course the axons give
* This observation was made on dogs in the following way: The animals
were prepared, and cannulz# were introduced into their carotids. The
dogs being severally in a state either of activity or somnolence, a quantity
of Cox’s fluid was run into the cannule, and the neurons thus fixed in situ.
Sections of the cerebral cortex were sybsequently cut and examined, and
it was found that the gemmules were retracted in those animals which were
in a state of activity at the time of the experiment, while in the somnolent
animals they were in protrusion. These observations, however, still await
confirmation.
SYNAPSES 7
off branches at right angles to tlfmselves; these are known as
collaterals, and are destined to convey impulses to the proto-
plasmic processes of other neurons.
Transmission of the Nervous Impulse.—It is probably to be
inferred from Lugaro’s observations (vide supra) that, when a
nervous impulse passes from onnee uron, a, through another, £,
to. a third, y, the collaterals of a cause certain gemmules on the
dendrons of 8 to react and to protrude. Contact being thus
ensured between a and #, the nervous impulse passes up one of
8’s dendrons through its cell-body and axis-cylinder to one of
its collaterals. Here reaction again occurs: one of y’s gemmules
is in turn protruded and the impulse passes on toy. During the
process other gemmules of the neurons concerned are retracted.
The sites of contact between neurons are called synapses, and
it is probable, as McDougall has pointed out, that they play a
most important rdle in physical processes. I have just said
that, by the protrusion of gemmules, contact is made between
one neuron and another; but, as a matter of fact, it is probable
that contact is incomplete and that a very thin layer of inter-
neuronal tissue always intervenes and offers a certain amount
of resistance to the passage of a nervous impulse across the
synapse.
There is considerable evidence in favour of this resistance.
(1) The ordinary rate of conduction of a nervous impulse along
a nerve-fibre is about 50 metres per second, and there is no
reason to suppose that any delay occurs in its transmission
through the cell-body of a neuron; indeed, such evidence as is
available negatives the suggestion. But when the impulse has
to be transmitted across a synapse, as in ordinary reflex action,
there is delay in the transmission amounting to one-hundredth
of a second—time enough for the impulse to have travelled
another third of a metre if the nerve-tract were continuous
instead of interrupted. (2) The rate of transmission of an
impulse along a nerve-fibre is constant and independent of the
intensity of the stimulus; whereas an increase in the intensity
of a stimulus increases the rapidity with which a reflex action
takes place. This shows that there is a certain amount of
resistance to stimuli, which is overcome less readily when these
are weak than when they are strong and is to be conceived as
occurring at the synapse. (3) If a series of sensory stimul,,
which are individually insufficient to provoke a reflex, be applied
in rapid succession to a reflex-provoking area, reflex action
results. This, again, is indicative of synaptic resistance.
8 | MIND AND ITS DISORDERS
Other characteristics of syfaptic transmission, as shown by
the study of reflex action, are susceptibility to fatigue and to
the influence of drugs, necessity for good circulation in the
neighbourhood of the synapse, and irreversibility of direction of
the nervous impulse (law of forward conduction). The trans-
mission of impulses along nerve-trunks, on the other hand, is
influenced but little by drugs or by interference with the circu-
lation, is practically insusceptible to fatigue, and may take place
in either direction.
For the present I will allude to only two more characteristics
of reflex action, viz., (a) after-discharge and (bd) facilitation.
(a) If a stimulus be applied to a nerve-trunk connected with a
muscle, the muscle ceases to contract almost synchronously with
cessation of the stimulus; but if contraction of the muscle be
induced reflexly (through a reflex arc), irregular contractions of
the muscle continue for some time after cessation of the stimulus —
(after-discharge). (b) If a reflex be capable of being stimulated
through two or more receptive (sensory) areas, and if subliminal
stimuli be given to these (stimuli which are insufficient indepen-
dently to provoke the reflex), reflex contraction occurs when both
areas are stimulated together, the cumulative action of the two
subliminal stimuli being sufficient to induce a nerve-current in
the “ final common path ”’ (facilitation). For example, a sudden
sound and a flash of light, if of sufficient intensity, are each
capable of inducing reflex closure of the eyelids. This reflex
closure will also take place if two such stimuli, neither of which
is sufficiently intense independently to provoke the reflex, occur
simultaneously or even with a short interval of time between
them. Another example of facilitation which has a closer
bearing on the mental processes presently to be considered is the
following: if a spot be found upon the cerebral cortex of a dog,
the stimulation of which produces a movement which can also
be produced reflexly, and if subliminal stimuli be applied simul-
taneously both to the spot on the cortex and to the receptive
area of the reflex, movement will result, although either stimulus
alone is insufficient to induce the movement. Inter alia this
explains why reaction to a stimulus takes place more quickly
when attention is directed to the idea of movement than when
it is directed to the stimulus.
To explain these phenomena McDougall has conceived every
neuron to be charged with a certain quantity of nerve-force,
which he calls “‘ neurin”’ or “‘ neurokyme’”’, much in the same way
as a Leyden jar is charged with electricity. The effect of any
HIERARCHY OF THE NERVOUS SYSTEM 9
stimulus to a neuron is to set free in it a further quantity of
neurokyme. When a neuron thus becomes surcharged, the
excess of neurokyme overflows at its synapses. Naturally the
overflow is more likely to take place at some synapses than at
others, especially at those which are in constant use and where
overflow has taken place before. Considerations such as these
give us a peep at the physical basis of “‘ habit’.
When one neuron receives from another an overflow of neuro-
kyme, it tends in its turn to become surcharged and to overflow
into other neurons, and so on. The ultimate result is either
diffusion of nerve-force if the quantity of neurokyme in the
nervous system happens to be at a low ebb or, more commonly,
there is a final overflow into motor tracts and, conformably to
the law of conservation of energy, contraction of muscle results,
neurokyme being converted into work.
Mind.—When we speak of mind we mean that faculty or
function in us by which we become aware of our surroundings
and their distribution in space and time, by which we experience
feeling, emotions, and desires, and are able to attend, to re-
member, to reason and to decide.
In the succeeding pages it will be shown that, concomitantly
with affective tone, sensation is an essential attribute of conscious
organisms and that all the more complex mental functions are
derivable therefrom. In the course of evolution, sensation,
which is presumably an attribute of even the lowest unicellular
organisms, is believed by the author to exist in the individual cells
of the highest multicellular organisms, such as man. Every cell
is regarded as having sensation, the neuron being the most
sensitive of all, sensation therein being aroused by a surcharge
of neurokyme. Sensations of cells of the other highly organized
tissues (skin, retina etc.) are represented again and again on the
following scheme.
Scheme of the Nervous System.—Sensations aroused at the
periphery are first represented in bipolar cells, the dendrons of
which are usually devoid of gemmules. They are next repre-
sented in cell-stations, whence there is a divergence of paths of
conduction, one path going cerebrumwards, and the other cere-
bellumwards (vid the restiform body). It is significant that no
such station occurs in the olfactory path, which has no con-
nection with the cerebellum. Following up the cerebro-petal
path, we find that sensations are next represented in groups of
cells which may be classed together under the heading of “ basal
ganglia ’’, the next representation being in the sensory so-called
IO MIND AND ITS DISORDERS
“centres ’’ of the cortex cerebri, which, together with the motor
area in front of the fissure of Rolando, have received the name of
projection centres. The highest representation of sensation is
in the remainder of the cerebral cortex, which was divided by
Professor Flechsig into four great association centres. P
A question, which naturally arises in this connection, is ““ How
far down the nervous system do consciousness and apprehended _
sensation, or rather their physical bases, extend ?’”’ This has
partially been answered by Head and Holmes in an illuminating
paper published in Brain (November, 1911). According to these
investigators, it would appear that sensations requiring little
discrimination, such as pain, pressure, tickling, scraping and
vibration, are registered, perhaps finally, in the optic thalamus;
while sensations requiring discrimination, such as warmth, cold,
the sense of position and the estimation of weight, size and con-
sistence, are registered, perhaps exclusively, in the projection
areas of the cerebral cortex. And it may be inferred from
analogy that elementary sensations of light, sound, odour and
flavour, may be registered in homologous basal gangla, while
the discrimination of various sense qualities takes place in
corresponding projection areas.
The diagram will help to elucidate the above points. The
connections figured between the projection and association areas
are in accordance with Flechsig’s researches, and it will be
observed that the cortex cerebri is a colony of neurons, having
very numerous intercommunications. It is a colony of the most
sensitive cells of the organism. The combined sensation of
these neurons constitutes the consciousness of the colony, and
this is none other than the consciousness of the organism. This
combined consciousness is aroused whenever resistance at the
synapses is overcome by the escape of a surcharge of neurokyme
from one set of neurons to another.
A little consideration of the phenomena of unconsciousness
will show the importance of sensation in establishing mental life.
When a person faints, his skin becomes numb and finally anzs-
thetic; his vision grows indistinct till all is dark; sounds grow
more distant; there is, perhaps, a momentary sound of rushing
waters, then all is silent. When a patient is anesthetized,
he loses sensation and is therefore unconscious; his mental
phenomena and sensations disappear part passu.
In the unconsciousness of deep sleep no sensations are per-
ceived and, at times, it requires a strong sensory stimulus to wake
the sleeper, the conscious mind being in abeyance. The new-
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FIG. 3.—SCHEME OF THE NERVOUS SYSTEM.
The dotted line surrounds the neurons subserving the function of the
superficial reflexes.
(a) Peripheral nerves.
pharyngeal. (d) Pyramidal tract.
nerve.
(7) Optic nerve and tract.
(m) Olfactory tract.
(b) Olfactory nerves.
(h) Glossopharyngeal and pars intermedia.
(k) Mesial fillet.
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UNCONSCIOUS MENTATION si i
born infant, whose sensations are as yet but feebly developed,
spends the greater part of its time in sleep. In the coma of
epilepsy, apoplexy, intracranial pressure, diabetes, ureemia etc.,
the criterion of unconsciousness is lack of response by the patient
to pin-pricks, shouts, electric batteries or any other form of
powerful stimulus which the ingenuity of the physician can
devise. If none of these stimuli evoke a response, the patient’s
mentation is considered to be in abeyance; for the time being
he has no mind. In the case of children deprived of the senses
of hearing and vision from birth there results the condition
known as “ idiocy by deprivation of the senses ”’; they experience
fewer sensations than healthy children and are therefore mentally
deficient.
Finally we have Strumpell’s classical case of the patient who
suffered from universal anesthesia, bilateral deafness and uni-
lateral blindness. All knowledge of the outside world came to
him through his sound eye and, when this eye was closed, he
went to sleep; in other words, he lost consciousness.
Our general conclusion is, therefore, that sensation is essential
to consciousness and, in our further considerations, it will be
shown that mind, with all its higher functions of memory, dis-
crimination, will, reason etc., may be evolved from sensation,
which is indissolubly associated with affective tone, without
invoking the aid of a “‘ thinking principle’’, “‘ apperception ”’, or
any other form of higher intellectual spontaneity.
It will be objected that this theory does not explain the origin
of sensation and that it involves the adoption of the hylozoistic
view that sensation is an attribute of matter. Arguments are
by no means wanting that the hylozoistic view is correct, but
whether sensation is an attribute of matter or not is a meta-
physical question, which probably can never be settled and
would be out of place in a practical handbook; but the author
believes that the above mode of thinking of the nervous system
in its relation to mind will at least prove helpful to the psychol-
ogist and the student of insanity.
Unconscious MENTATION.
On the opposite page the question was raised “‘ How far down
the nervous system does consciousness extend ?”’ and it was
partially answered. The question referred to consciousness of
the organism as a whole, but there is reason to believe that
groups or colonies of neurons in subservient lower portions of
IZ MIND AND ITS DISORDERS
the nervous system have something akin to consciousness of
their own. Pavloff’s conditioned reflexes, for example, support
this view. This consciousness forms no part of the consciousness
of the whole organism, and the nervous functions of such neuronal
colonies are therefore regarded as unconscious.
There are, however, many more unconscious nervous operations
than these, including some whose physical basis undoubtedly
lies in the cerebral cortex. In the following chapters we shall
have occasion to refer to sensations, percepts, ideas, desires and
even judgments, which are not registered in conscious memory;
they are unconscious. There are, moreover, many incidents and
situations which, although remembered for a time, are later
completely forgotten. These also constitute a large part of the
unconscious mind. )
In due course such groups of phenomena will be considered in
detail. They are mentioned now for the purpose of stating that
nothing is known of the physical basis of the unconscious.
Hitherto it has been studied by psychological methods only. It
would be easy to hazard a conjecture that some ideas remain
unconscious because certain gemmules refuse to protrude, and
thus to make the contact necessary to arouse conscious memory
or to discern an analogy between synaptic resistance and the
unconscious resistance to the revival of certain memories; but
this would be mere guesswork. For the present we must
admit our total ignorance of the difference between the physical
processes underlying subconscious and unconscious mental
phenomena and those subserving conscious thought.
Purely psychological research, however, has furnished ample
evidence that the unconscious part of the mind contains far
more psychical material than the conscious, which is merely the
small perceptible part. In this sense the mind has been com-
pared with an iceberg, nine-tenths of which is submerged while
only one-tenth 1s open to direct observation. The submerged
portions of both the mind and the iceberg can be investigated
by very difficult soundings and probings and by observation of
the behaviour of the perceptible portions under unusual con-
ditions. Methods of penetrating the deeper recesses of the
mind will be set forth in subsequent chapters.
GEA helt
SENSATION.
WuAT sensation is we do not know. Some psychologists seek to
explain it by the principle of “‘ relativity ’’, which recognizes that
every sensation is experienced in relation to some other sensation,
that we are conscious only as we are conscious of change. Black
can only be felt in contrast to white or, at least, in distinction
from a paler or deeper black; a sound can only be sensed as con-
trasting with other sounds or with silence. If all the stimuli at
any given moment were to continue ad infinitum without change,
sensation, and therefore consciousness, would disappear.
All this we are prepared to admit, given sensation ; but this
doctrine, which is known as the “ Law of Relativity’”’, begs the
whole question. If change of stimulus is all that is required to
arouse sensation, every stone in the road must have sensation,
exposed as it is to an enormous variety of stimuli. Indeed,
although its supporters would not admit it, the doctrine is hylo-
zoistic at bottom; it assumes that sensation is an attribute of
matter, a view with which I am disposed to agree, but to discuss
it would lead us into the domain of metaphysics.
When we think, we think of something, of some object in our
present or past environment; and we think of it in terms of the
sensations aroused by the object. If, for example, we have an
idea of a cigar, the idea is composed of revived visual sensations
(brown image of characteristic shape), olfactory sensations
(aroma), perhaps auditory and gustatory sensations (crackling
when rolled between the finger and thumb, saltish taste), tactile
sensations, etc. Such sensations are the elemental processes of
which consciousness is composed, and are associated with physical
processes in definite bodily organs.
A simple sensation, as the word is used here, is a pure abstrac-
tion. Nobody ever experienced the colour red, the tone C or
the temperature 100°, and nothing else: these are but attri-
butes of objects in the environment of the individual who sees
the colour, hears the tone or feels the temperature. It is, how-
ever, useful, and indeed necessary, to study such simple sensa-
13
I4 MIND AND ITS DISORDERS
tions in the abstract before proceeding to the consideration of
higher mental functions.
Sensations may have four attributes—quality, intensity, dura-
tion and extent. The quality of a sensation depends upon
the specific nature of the peripheral sense-organ and associated
sensory nerves, by the stimulation of which the sensation is
aroused (eye, ear, tongue or Schneiderian membrane) and upon
the nature of the stimulus to the sense-organ. All forms of
stimulation of the optic nerve (electrical, mechanical or thermal)
give rise to a sensation of light and to no other kind of sensation.
All forms of stimulation of the auditory nerve give rise to a
sensation of sound and to no other kind of sensation, and so
forth. All highly specialized nerve-tracts have their own specific
qualia. On the other hand, a red-sensation is different from a
blue-sensation, because there is a difference in the nature of the
stimulus to the retina, depending upon the different wave-lengths
of the two kinds of light. In the domain of hearing, a C-sensa-
tion is different from a D-sensation on account of the difference
in the nature of the stimulus to the organ of Corti, depending on
the difference in the rate of vibration of the air in the two cases.
Similarly a sweet-sensation is different from a salt-sensation, an
eau-de-Cologne sensation from a white-rose sensation, and so
forth. These are differences in the quality of sensation.
By the intensity of a sensation we mean that attribute by
which one sensation is stronger or weaker than another. The
sweetness of saxin is more intense than the sweetness of sugar,
but the quality of the sensation is the same in the two cases.
When a tuning-fork is struck, the resulting sound is at first more
intense than subsequently when the fork begins to ring off; but
the quality of the sound remains the same. Similarly one light
may be more intense than another of the same kind, and one
odour more powerful than another, although both may be of the
same quality.
By the duration of a sensation is meant the length of the period
during which it is experienced; and by its extent is meant the
amount of space over which it spreads; e.g., the colour red may
occupy half the visual field or a sensation of pain two square
inches of the forearm. On the other hand, certain sensations
(olfactory, gustatory and auditory) cannot be said to have any
extent.
A sensation is then made up of quality, intensity, duration
and extent; and no sensation can exist without at least the first
three of these attributes.
CLASSIFICATION OF SENSATIONS 1S
Sensations are classified according to the sense-organ to which
a stimulus must be applied in order to produce them (eye, ear,
nose etc.); and, according to whether the sense-organ is on the
surface of the body or not, they are divided into two classes,
sensations of the special senses and organic sensations. The
eyes, ears, nose, tongue and skin, being all more or less super-
ficially situated, hearing, smell, taste, and the cutaneous sensa-
tions are grouped together as the special senses (the “ extero-
ceptive field’ of Sherrington): and, inasmuch as the muscles,
tendons, joints, alimentary canal, lungs etc., are more
deeply situated, sensations from these organs are grouped
together as organic sensations (the “ proprioceptive field’”’ of
Sherrington).
This division into organic sensations and special sensations is
obviously of an arbitrary character. All sense-organs are peri-
pheral so far as the brain is concerned, and there is no essential
difference between a muscle-spindle and a tactile corpuscle. If
the reader is inclined to object that the stimulus in one case is
from without and in the other from within, let him make firm
external pressure on his own abdomen and he will find that the
stimulus from without can give rise to “ organic ’’ sensation; or
let him blow up his Eustachian tubes (Valsalva’s experiment),
and he will find that stimulus from within can give rise to
‘“ special ’’ sensation (hearing). It is true that the deep situation
of the end-organs of so-called “ organic ’’ sensations prevents
their being so accurately observed as the so-called “ special ”’
senses; but this does not constitute a real psychical difference
in their nature. We must therefore reject the distinction
between organic and special sensations as serving no purpose in
the study of psychology, although there may be physiological
differences.
Our classification of sensations will therefore be as follows:
Visual sensations (stimulus: hght)—
Sensations of brightness.
Sensations of colour.
Auditory sensations (stimulus: air-vibration)—-
Sensations of noise.
Sensations of tone.
Olfactory sensations (stimulus: ? chemical action of
odorous particles).
Gustatory sensations (stimulus: ? chemical action of
certain substances).
16 MIND AND ITS DISORDERS
Cutaneous sensations—
Sensations of pressure or touch (stimulus: mechanical).
Sensations of pain (stimulus: mechanical, thermal,
electrical or chemical).
Sensations of warmth (stimulus: thermal).
Sensations of cold (stimulus: thermal).
Head and Rivers have demonstrated that the skin is supplied by two
distinct systems of sensory nerves, the “ protopathic ’’ and the “ epicritic ”’.
The former depends upon definite sensory end-organs and the areas be-
tween these are supphed with epicritic sensibility. The protopathic end-
organs have a high threshold—e.g., the ‘‘ heat spots’ do not respond to
temperatures below 37° C. or the ‘‘ cold spots’’ to temperatures above
26° C. in the absence of epicritic sensation. Accuracy of localization
is dependent upon the more recently evolved epicritic system. It
should be mentioned, however, that these observations have not
passed unchallenged.
Muscular sensations (stimulus: contraction of or pressure
on muscle).
Tendinous sensations (stimulus: stretching of tendon).
Articular sensations (stimulus: pressure on articular
surfaces).
Circulatory sensations (stimulus: change in arterial or
venous tension).
Sensations from the alimentary canal—
(a) Pharyngeal sensations (stimuli: mechanical,
thermal or chemical; dryness of ‘mucous
membrane).
(>) Esophageal sensations (stimuli: mechanical,
thermal or chemical; antiperistalsis).
(c) Gastric sensations (stimuli: distension, presence
of abnormal substances in the gastric con-
tents, dryness of the mucous membrane; anti-
peristalsis).
(dz) Intestinal sensations (stimuli: distension, peri-
stalsis).
Respiratory sensations (stimuli: excessive or deficient
supply of oxygen, irritating substances).
Urinary bladder sensations (stimulus: distension).
Sexual sensations (stimuli: change of blood-supply and
secretory activity of genital apparatus, contraction of
muscle etc.).
Static sensations (stimulus: difference of pressure in
semicircular canals).
ATTRIBUTES OF SENSATION ay,
These are the most important, but the student will be able to
supplement the list from his experience of cases of heart disease,
thrombosis, cholelithiasis etc. Moreover, it is believed by
certain writers that some people are endowed with senses of
which others have no experience. The Psychical Research
Society claims to have accumulated a mass of evidence that
telepathy and other phenomena, usually classed as “ occult ”’,
undoubtedly occur; from which it should be concluded that
people who have experienced any such manifestations must be
endowed with a sense of which most of us are deficient. Would
that we had some such sense to aid us in the solution of difficult
psychological problems !
Since the intensity, duration and extent of a sensation are
always the intensity, duration and extent of some quality of
sensation, it follows that quality is the most important attribute
which we have to consider. For convenience, however, it is
more useful to consider the minor attributes of sensation first.
The questions which arise in this connection are: What is the
smallest intensity, duration and extent of a sensation that can
be experienced in the various sense departments? By how
much must a stimulus be increased in order to cause an increase
of sensation ? And what is the greatest intensity, duration and
extent of each that can be attained ?
Intensity.— Just-noticeable sensations. If we go into a room
from which all light is excluded, we experience a sensation of
blackness; but, in addition to this, we have many faint sensations
of light, due to stimulation of the retina by the ordinary processes
of metabolism. Owing to this intrinsic retinal light, there is con-
siderable difficulty in determining the least light-intensity which
is just noticeably brighter than the black of the field of vision. It
has, however, been estimated, by passing a current of electricity
through a platinum wire until it became just visible, that the
least noticeable intensity of light is approximately one three-
hundredth of the light of the full moon reflected from white
paper. It is curious that, so far as I am aware, this intensity
has never been expressed in terms of candle-power, the usual
standard of measurement of light.
In audition, as indeed in all other sense departments, there
is considerable difference between individuals. As an average
result, however, it has been ascertained that a normal individual
can just hear the sound ofa cork pellet, weighing one milliigramme,
gt millimetres distant from the ear, falling through one milli-
metre on a sheet of glass. This result is obtained under the
a
18 MIND AND ITS DISORDERS
experimental condition of absolute silence, the reason for which
we shall see presently. Under similar conditions we would
find that an ordinary musket-shot could be heard at a distance
of 7,000 metres (about 34 miles).
The just-noticeable sensation for pressure differs in different
parts of the body. One five-hundredth of a gramme can be
sensed on the forehead, eyelids, temples, outer surface of the
forearm and back of the hand; but it requires no less than one-
twentieth of a gramme to be sensed on the cheeks, nose, palm
of the hand, abdomen and thigh. On the nails and heels the
just-noticeable weight is as much as one gramme.
Up to the present, the other senses have not been to any
extent subjected to investigation with a view to determining
the just-noticeable sensation in each case.
One sense may sometimes be ousted by another of great
intensity. For example, it sometimes happens that one is
unable to smell a flower or taste a delicacy on account of a noise
occurring when one attempts to do so. The one sense appears
to be capable of inhibiting the other.
Extent.—The senses that play the most important part in the
perception of space are those of touch and vision. Accordingly
these senses alone receive consideration in determining the
smallest amount of space which can be appreciated by them.
If two white threads placed together against a dark back-
ground at a convenient distance trom the eye, be gradually
separated, it is found that they can be seen as two instead of
one, when they subtend an angle of one degree at the cornea.
The appreciation of two cutaneous stimuli as separate from
one another varies enormously in different parts of the body, to
such an extent that it is doubtful whether any two parts of the
skin are the same in this respect. On the finger-tips, for instance,
two compass-points can be distinguished as two separate impres-
sions when they are one millimetre apart; but upon the skin of
the back the distance has to be 60 millimetres.
Duration.—In estimating the duration of a sensation we are
met with the difficulty that it does not immediately cease with
its stimulus. For this reason a rotating disc, half spectral red
and half spectral green, appears white. In order that the colours
may not fuse in the whole extent of the circumference of the
disc, it is necessary that the disc should rotate less rapidly than
four times per second: a light-stimulus of minimal duration gives
a visual sensation lasting one-eighth of a second.
In order to find the least noticeable duration of pressure, the
WEBER'S LAW 19
finger is lightly laid upon a toothed wheel, which is made to
rotate. At a certain velocity the teeth of the wheel cannot be
separately distinguished. From an experiment of this nature,
the minimal duration of pressure-sensations can be determined.
Although the minimal intensity, duration and extent of sensa-
tions have been separately considered, it is to be observed that
the minimum in each case is dependent upon the other attributes.
For example, a point of light of given intensity may not be
appreciable to the senses, whereas a square foot of light of the
same intensity may be easily distinguished. Moreover, if this
square foot of light lasts but a fraction of a second, it may be
inappreciable to the senses; whereas, if it be allowed to last
for half a minute, it may become perfectly obvious.
The maximal intensity of sensations is, as a rule, so unpleasant
or painful that the value of introspection is destroyed. The
greatest appreciable intensity of sensations, therefore, cannot be
determined.
The maximal extent of visual and cutaneous stimuli is pro-
duced by stimuli of the whole of both retinz and the whole of
the skin respectively.
The maximal duration of sensations has not been determined.
Weber’s Law.—We now come to the last question: By how
much must a stimulus be increased in order to produce a just-
noticeable difference in sensation ?
It has been shown that the answer to this question varies for
the different sense modalities. A light stimulus must be in-
creased by one-hundredth in order to produce a clear increase
of sensation. Sound and pressure stimuli must be increased by
one-third, and muscular (estimation of weights) by one-seven-
teenth, for the production of a clear increase of sensation.
To take an example: If a weight of one gramme be allowed to
rest on the hand, it is necessary to add one-third of a gramme,
and if a weight of a pound be allowed to rest on the hand, it is
necessary to add one-third of a pound, and no less, in order that
the observer shall notice an increase of weight in each case.
This law was discovered by the physiologist Ernst Heinrich
Weber, and has accordingly been called after him, ‘“‘ Weber’s
law’’. It was, however, only in special cases that he examined
its validity. The general applicability of the law was demon-
strated by Gustav Theodor Fechner, who reduced it to the more
general form: Sensation increases as the logarithm of the stimulus,
the logarithmic base varying for the different sense modalities.
The law is not absolutely correct, however, for sensations of
20 MIND AND ITS DISORDERS
very high and very low intensity: it applies only to those of
moderate intensity.
Weber’s law is constantly being exemplified in our everyday
life. It explains why an artificial light is useless in a room
already illuminated by the sun while it is of great utility in the
dim twilight, why we can hear a pin drop in a silent room while
we cannot hear ourselves speak in a boiler-shop and why we
cannot feel a tumour in a patient’s abdomen when he contracts
his abdominal wall.
There are various interpretations of the law. According to
the psychological view, each sensation consists of a large number
of elementary units, and those who hold this view speak of
‘quantities ’’ of feeling. Their interpretation of Weber’s law is
that the quantities of our feelings are related logarithmically
to the quantity of stimulation arousing those feelings. Psycho-
physical interpretations are based on the fact that weak stimuli
make nerve-tissue more excitable without overcoming the resist-
ance at the synapses, a feature which is exemplified by Sherring-
ton’s experiments illustrating “facilitation”. Elsas has pointed
out that a chemical balance, in so far as its frictional resistance
to indicate small changes of weight is concerned, obeys Weber's
law. Ebbinghaus supposed the intensity of sensation to depend
on the number of neural molecules which are disintegrated in
a unit of time.
It would seem that a psycho-physical interpretation of Weber’s
law lies nearer the truth than the psychological which, after all,
is but a restatement of the facts; but it is beyond the scope of
this work to enter into a discussion of the relative merits of
these various hypotheses.
We now proceed to the consideration of sensation qualities.
VISUAL SENSATION.
The characteristic quality of visual sensations is colour. The
number of different colours that can be normally distinguished
has never been determined; it amounts to many thousands.
The different shades of colour that can be distinguished in the
solar spectrum alone number 160; but many new colours can
be constructed by mixtures of these. Further, the solar spec-
trum does not include white, black or grey, which are also colours
from a psychological point of view: the physical fact that white ~
light may be resolved by means of a prism into all the colours of the
rainbow has no bearing upon the psychological quality of white.
VISUAL SENSATION 21
If a spectral colour be illumined by white light and the intensity
of that light be increased or diminished, the guality of the colour-
sensation changes; a spectral red, for example, becomes a pink
or a brown when the intensity of the illumination is respectively
increased or diminished. It has been shown that each of the
spectral colours gives about 600 sensation qualities during the
gradual intensifying of its illumination with white light. Similar
observations might be made on the number of sensation qualities
resulting from an intensively graduated illumination of a spectral
red by a blue light, and so forth.
The sensitive layer of the retina consists of rods and cones.
At the fovea centralis, the spot of clearest vision, only cones are
present. In the region surrounding this, rods and cones are
present in fairly equal numbers; while the periphery is almost
devoid of cones. The cones are stimulated by bright light only,
and it is through their reaction to hght that we are capable of
appreciating colour. The rods are much more sensitive and are
rapidly exhausted by bright hight. It is by their reaction that
we are enabled to see in a light too feeble to stimulate the cones,
but they do not react to colour; coloured objects in a dim light
look black, white or grey, red objects appearing black because
red does not stimulate the rods. The difference between the
excitabilities of the rods and cones may be studied on a starlit
night when one finds that many of the dimmer stars, which are
easily seen at the periphery of the retina, disappear if one looks
straight at them, so that the image falls on the rodless fovea.
There are about half a dozen theories of colour-sensation
extant, none of which appears to the present writer to be quite
satisfactory. A satisfactory colour theory must be able to
account for all the facts of colour-blindness. It must account
for cases of “ total’’ colour-blindness in which all visual images
appear as shaded drawings, for cases of “ red-blindness’’ and
“ green-blindness ’’ as well as for the more frequent cases of
“red-green blindness ”’ and for cases of monocular colour-blind-
ness; it must also account for the fact that we never come across
cases of black-white-grey blindness with retention of vision for
spectral colours.
Edridge Green believes that the function of the rods is to
manufacture visual purple, which accumulates round the cones.
Light has the property of decomposing the visual purple and
at the same time of generating an electric stimulus to the cones,
which varies in character with the wave-length of the ray of
light. Discernment of the colour from the character of the
22 MIND AND ITS DISORDERS
stimulus is the function of the occipital cortex. Edridge Green
distinguishes two classes of colour-blind persons, viz., those
who are unable to see the colour of one or other end of the spec-
trum, and those who cannot recognize the difference between
certain colours. The latter can only see five, four, three or fewer
of the primary colours. |
Wundt supposed every retinal excitation to be compounded
of two separable constituents, a colour excitation and a bright-
ness excitation. When the achromatic excitation occurs, we
sense black, white or grey. A chromatic excitation implies the
presence of the achromatic. When a chromatic excitation
occurs, any difference in the sense-quality results from a varia-
tion in the wave-lengths of light.
The theory of Hering takes cognizance of the fact that there
are only six colours which cannot by introspection be analyzed
into simpler colours. These are black, white, red, green, blue
and yellow. Violet is clearly analyzable into red and blue,
orange into red and yellow, and brown into red and black. The
theory assumes that there are three kinds of visual substance
in the retina, probably lipochromes, whose katabolism gives
white, red and yellow, while their anabolism gives black, green
and blue respectively.
The retina is not uniformly sensitive to colour over its whole
surface. It may be demonstrated by means of the perimeter
that there are three colour-zones merging into one another:
an inner where all colour-tones are accurately estimated, this
gradually passing into an intermediate zone where all colours
are apprehended as blue, yellow, black, white or grey; and an
outer zone in which all colours are apprehended as black, white
or grey. These phenomena, when considered in conjunction
with the fact that red-green is the most common variety of
colour-blindness and blue-yellow a much rarer variety, suggest
that black-white-grey vision is the first in order of evolution,
blue-yellow next and red-green the last to develop. They also
suggest that the cones are more recent in their evolution than
the rods.
Near the centre of each retina there is a spot, at the entrance
of the optic nerve, which is totally blind. This is easily demon-
strated. If the accompanying diagram be held at a distance
of about 12 inches in front of the left eye, the right eye being
closed, and if the reader gaze at the cross, the spot will dis-
appear. It is, however, to be observed that the spot is replaced
by the white of the paper, not by a blank. And if the reader
AFTER-IMAGES 23
take the trouble to copy the diagram upon the middle of his
morning newspaper and carry out the observation again, it will
be seen that the blind-spot is filled in with print. If a vertical
or horizontal line be drawn, that line does not appear shorter
when the middle of its image falls upon the blind-spot. Such
observations demonstrate that, owing to perceptual experience,
the blind-spot has the same spatial value as the rest of the
Fic. 4.
retina and tliat any area whose image falls upon it is filled up
in the same way as the rest of the surface under observation.
Complementary colours are those whose combination gives
white as a result, or at least a grey with no admixture of spectral
colour. Such complementary colours are carmine and _ bluish-
green, red and verdigris, orange and greenish-blue, yellow and
blue, yellowish-green and violet, green and purple; in a sense,
black and white may also be regarded as complementary colours.
If any of these colours be presented in the field of vision, the
rest of the field is tinged with the complementary colour. This is
best demonstrated by the following experiment. On a piece of
black cloth lay a square of grey paper with a hole in the centre.
Under the grey paper pass towards the hole a slip of white or
coloured paper. As soon as the coloured slip makes its appear-
ance in the hole the grey square is immediately tinged with the
complementary colour. If the slip be white, the grey paper
darkens; if carmine, it is tinged with bluish-green; if blue, with
yellow, and so on. This is the phenomenon of simultaneous
contrast.
The best examples of successive contrast are negative after-
images. If we look at the sun for a moment and then look at
a grey background, we see on the background a dark grey or
bluish-grey disc, the negative image of the sun. This is an
extreme case; but after-images are easily obtained by gazing
for an extended time, say one minute, at a strip of coloured
paper.. It is found that the after-image is of the complementary
colour to that given in the stimulus.
It is also to be observed that the phenomena of contrast are
effective in the after-image. This is, perhaps, best exemplified
by Hering’s original experiment, which is as follows:—Lay
two small strips of equally dark grey paper on a background
24 MIND AND ITS DISORDERS
of which one half is white and the other half black, in such a
way that they lie on opposite sides of the border-line and parallel
toit. Gaze for one minute at a point on the border-line. Close
or cover the eyes, and the negative after-image appears. The
difference of the brightness of the strips in the after-image 1s
generally much greater than during direct vision. A phase
occurs in which the difference in brightness of the two halves of
the background disappears, and both after-images of the strips
are still clear, one brighter and one darker than the background.
This experiment shows that the difference in the brightness of ©
the after-image depends upon a different state of excitation of
the corresponding parts of the retina; and from this we must
conclude that the two parts of the retina corresponding to the
two strips of equally dark grey paper were differently stimulated
during the original observation. The conclusion is, therefore,
that ‘‘ contrast is occasioned, not by a false idea resulting from
unconscious conclusions, but by the fact that the excitation of
any portion of the retina, and the consequent sensation, depends
not only on its own illumination, but on that of the rest of the
retina as well’’.*
We have observed that in negative after-images the colours
are complementary to those given in the original stimuli. In
positive after-images the colours are an exact reproduction of
those given in the original stimuli. They are not as easily
induced as negative after-images; but, when they occur, they
precede the formation of the negative after-image.
AUDITORY SENSATION.
The characteristic quality of auditory sensations is “ pitch ”’.
The notes of a piano give tones of different “ pitch ’’, their differ-
ence depending upon the rate of vibration of the wires and the
resulting rate of vibration of particles of air.
The normal ear can distinguish many more tones than are
represented on an ordinary piano; not only of a higher and
lower pitch, but also many intermediate tones which cannot be
produced on a piano without special adaptation of the instru-
ment. By means of various scientific appliances it has been
demonstrated that we can normally distinguish about 11,050
different tones. This number corresponds to the number of
hair-cells in the cochlea, yet physiologists are not inclined to
the view that each hair-cell is tuned to a particular tone.
* James, “ Principles of Psychology,” vol. ii., p. 19.
CUTANEOUS SENSATIONS 25
Besides musical tones, the ear is capable of distinguishing
many varieties of noise. Noises are of two kinds, the first being
due to air-vibrations of insufficient duration to give rise to a
musical tone (two or three vibrations of extreme rapidity), and
the second to a confused mixture of musical tones among them-
selves or with noises of the first class. To the first class belong
eer bitice we banes.s. cracks “ etc;; andito the second class: the
rumble of the street and the roar of the waterfall.
The appreciation of pitch is not exactly the same for the two
ears. A given tone in the middle of the musical scale is com-
monly apprehended by the right ear as being of a slightly higher
pitch than by the left ear, the difference corresponding to that
of two or three vibrations per second for the middle notes of
a plano.
The same tone gives a different sensation quality when sounded
upon different musical instruments. This depends partly upon
the mechanism of the particular instrument; cf. the percussion
of a piano, the scraping of a violin and the reedy vibration of
an oboe. The different timbre or clang-tint of these instruments
depends also on the formation of overtones. Overtones are
tones of less intensity and higher pitch than the fundamental
tone, which depend for their formation upon partial vibrations
of the column of air in a wind-instrument or of the string in
string-instruments.
It has been suggested that the appreciation of pitch obeys
Weber’s law, the pitch increasing in direct proportion to the
logarithm of the vibration-rate.
CUTANEOUS SENSATIONS.
The cutaneous sensations are four in number—pressure or
touch, pain, warmth and cold.
These are four distinct sense-modalities, as different as those
of vision and hearing, each having a series of end-organs sub-
serving its own particular function. According to von Frey,
sensations of pressure are derived from the hair-bulbs and
Meissner’s corpuscles, those of pain from the free nerve-endings
in the epidermis, those of warmth from Ruffini’s cylinders and
those of cold from Krause’s end-bulbs.
With the head ofa pin it may be ascertained that the sensation
of pressure is more intensive at some spots of skin than at others,
and with the point that the sensation of pain is more intensive
at some spots than at others. Similarly, with a suitable blunt
26 MIND AND ITS DISORDERS
instrument so adapted that its point can be kept warm or cold, ©
it may be ascertained that there are maximum spots for warmth
and maximum spots for cold. These spots are respectively
known as the pressure-spots, pain-spots, warm-spots and cold-
spots. Of these, the pain-spots are by far the most numerous,
and the cold-spots are more numerous than the warm-spots.
It has been found that these spots are not always in identically
the same place, but that each moves about over a small area of
skin. It would be more strictly. true to say that there are
“blotches ’’ of skin for these various sensations, and that these
“blotches ”’ slightly overlap one another.
The pressure-spots are situated over the hair-bulbs and are
consequently to be found on the “‘ windward ”’ side of the hairs.
Weak sensations of pressure can be evoked by moving the tips
of the hairs. Pressure-spots are not, however, limited to hairy
parts of the skin: they are quite as numerous on the palm of
the hand and the sole of the foot. We soon become adapted
to sensations of pressure, e.g., pressure of clothing, because
the pressure-sense is easily fatigued.
Similarly the sense of temperature is easily fatigued. This
may be demonstrated by Locke’s experiment :—Fill three basins,
one with warm water, one with cold and the third with water
of moderate warmth. Place one hand in the first basin and one
in the second. After a minute, place both hands in the third
basin. The water will feel warm to the hand which has been
in the cold water, and cold to the hand which has been in the
warm water. But for the rapid exhaustion of the cold-sense,
our morning tub would be almost intolerable.
TASTE:
There are four taste-qualities:—sweet, salt, sour and bitter.
If the nostrils be plugged with cotton-wool, the tongue pro-
truded and a number of substances thus tasted, it will be found
impossible to discover more than these four qualities of gustatory
sensation, either alone or in combination. Suitable substances
for this experiment are beef-tea, cod-liver oil, olive oil, alcohol
and oil of cloves. With some of these there may be an addi-
tional sensation of stinging or tingling of the tongue; but these
will, of course, not be confused with gustatory sensations.
It has been discovered that certain of the lingual papille are
sensitive to only one of the four taste-qualities, those exclusively
sensitive to bitter being situated at the posterior part of the
tongue.
SMELL 27
Sensitiveness to one taste-quality may be fatigued while the
other taste-qualities remain unaffected. This would appear to
indicate that each gustatory cell subserves a specific taste-
quality.
A certain amount of contrast effect can be demonstrated
to exist in the case of gustatory sensations. For example, a
salt solution so weak that it cannot be tasted under ordinary
circumstances can be distinctly recognized as salt, if the mouth
be first washed out with a strong solution of sugar. In this way
it has been shown that a contrast exists between salt and sour,
and between sweet and sour. Bitter gives no contrast effects.
SMELL.
The psychology of smell is yet in its infancy, because the
Schneiderian membrane does not lend itself to direct stimulation
like the end-organs of other senses.
That smell plays an important part in the ordinary discrimina-
tion of flavour is shown by the fact that we cannot appreciate
flavour when the nasal passages are occluded.
The sense of smell is easily fatigued; and this phenomenon has
proved invaluable in elucidating its psychology. For example,
it has been found that, if the olfactory sense be exhausted for
iodine, the odours of oil of orange, heliotropine and alcohol can-
not be sensed at all, and that the sense is also partially exhausted
for a large number of other substances. Again, by this method
of exhaustion it may be shown that a large number of odours,
which give an unitary sensation of smell, are really composed
of a number of simpler olfactory sensations. Faded violets, if
persistently smelt, soon give but a disagreeable odour of faded
flowers. The initial odour of nitrobenzol is that of heliotrope;
this almost immediately gives place to that of bitter almonds;
this in turn gives place to benzene; then follows complete ex-
haustion for all three odours. From observations of this nature
it has been concluded that the innumerable olfactory qualities,
which are experienced as simple and unitary, are in reality
compounded of a comparatively small number of elementary
olfactory qualities, probably about eleven.
The practical experience of everyday life affords instances of
the compensation or neutralization of one smell by another. .
The odour of sanitas is antagonistic to that of feces, the scent of
areca-nut to that of carious teeth, and the odour of carbolic acid
to that of pulmonary gangrene. On the other hand, there is
28 MIND AND ITS DISORDERS
evidence of olfactory contrast between indiarubber and balsam
of tolu or cedar-wood, and between feces and musk. Epicures
also recognize a contrast between the odours of ham and cham-
pagne, cheese and claret, game and Burgundy.
THE SENSE OF POSITION AND MOVEMENT.
The sense of position and movement is made up of a large
number of sensations; mainly muscular, tendinous and articular.
Sandow’s exerciser is a useful piece of apparatus for demon-
strating the difference between these three kinds of sensation.
The dumb-bells should be connected together by a couple of
elastic bands. Place the foot upon one dumb-bell and stand
upright with the other dumb-bell held in the hand, the elastic
bands being put on the stretch. The sensation of tendinous
strain will be noticed. Now stoop so as to relax the tension of
the elastic bands. At the moment of complete relaxation there
will be noticed a distinct jog due to the approximation of articular
surfaces. Now stand upright once more and flex the arm to a
right angle. The characteristic sensation of muscular contrac-
tion will be noticed in the region of the biceps.
If the front of the forearm be rendered anesthetic by means
of an ether spray, it can be demonstrated that there is no differ-
ence between the sensations of voluntary muscular contraction,
e.g., of the flexor indicis, muscular contraction due to electrical
stimulation, and deep pressure upon the muscle. From this it
is to be inferred that muscular sensations are due to squeezing
of the muscle-spindles (the sensory end-organs of muscle) during
muscular contraction, and not to any cutaneous sensation from
movement of the skin by swelling of the muscle belly.
It is a matter of controversy how great a part is played in
the perception of movement and position by each of the above
sensation qualities. At present the claims of articular sensation
are rather in the ascendant, since Goldscheider has demonstrated
that, when a joint is rendered artificially anaesthetic, movement
becomes much less perceptible, whether it be active or passive.
But we shall have occasion to deal with this subject more fully
in the next chapter.
UNCONSCIOUS SENSATIONS.
The conclusions at which we have arrived in the present
chapter have been the result of introspection, special attention
having been directed to these sensations as they occurred; but
UNCONSCIOUS SENSATIONS 29
we have also to remember that the sensorium is constantly
receiving impressions, as it were automatically, independently
of consciousness and without our knowledge. As I write these
sentences, I experience no sensation of the pressure of my clothes,
of the chair I sit on or of the pen I hold; I do not notice the cool
air blowing across my cheek, the tick of the clock, the conversa-
tion beneath my window, the noise of passing vehicles, the
swaying of the lamp, the puffs of smoke from my pipe or even the
flavour of the burning tobacco. All these sensations are outside
my phenomenal consciousness, and it might be quite impossible
voluntarily to recall them; they are unconscious sensations.
For the present suffice it to remark that they might possibly be
recalled under hypnotism or by some other artificial aid; but
we shall have occasion to refer to them in another chapter.
CHAPTER IIT.
PERCEPTION AND IDEATION.
In the previous chapter we discussed the elementary sensations
without which mentation would be non-existent, disregarding the
external objects which, under normal circumstances, give rise
to those sensations. We now advance one step nearer to the
everyday working of mind and consider it in relation to things-
in-themselves. In the present chapter it will be shown that
the perception, apprehension and subsequent ideation of things-
in-themselves are merely the result of experience.
When I have an object before me, ¢.g., an orange, see it,
perhaps feel it and know that it is an orange, I have a percept
of it; when I think of an orange, I have an zdea of it. We shall
see later that there is practically no psychological difference
between these two processes, their chief difference being physio-
logical.
When I hold an orange before me, I experience sensations of
pressure, coolness and yellowness. If I drop it on the table,
there is a sensation of sound (a thud). If I eat it, there are
sensations of sweetness, sourness and the characteristic flavour
apprehended by the sense of smell.
When I think of some particular orange which I have seen, I
think of it in terms of these or some of these various sensations
of pressure, coldness, yellowness, flavour etc.; and, as a matter
of fact, I experience these sensations in a slight degree. There
is a faint visual, olfactory and tactile image of the orange, a
revived percept. I may further experience faint visual and
auditory images of the word “‘orange’’, as well as a muscular
sensation about the tongue similar to that felt when I say the
word “‘ orange’, the so-called “ kinesthetic equivalent ’’.
Three points are to be noted at this stage. In the first place,
these various sensations are not apprehended as separate: they
combine in the unitary percept or idea “‘ orange ’’; and it is only
by our psychological analysis, by introspection, that we discover
30
THE PHYSICAL BASIS OF PERCEPTION 5
that the percept or idea consists of sensations of various sense-
modalities.
Secondly, it is to be noted that not all combinations of sensa-
tion will form a percept or idea. For example, the sense-qualities
cold, red, sweet, high-pitched and painful refuse to combine to
form an idea from lack of such an experience.
Lastly, perception and ideation localize an object and give
it a definite shape, occupying a certain amount of space. It
follows that our percepts and ideas are in reality but abstractions,
just as much as sensations are. We cannot perceive or ideate an
object without giving it shape and placing it somewhere in space
with an environment of its own; and this environment is an
essential part of the perception. When we have a percept of an_
object, we are in reality making an abstraction from our percep-
tion of space in general.
The Physical Basis of Perception.—From the study of word-
_ perception we learn that the physical basis of visual percep-
tion is the anterior part of the occipital cortex,* and that of
auditory perception the second temporo-sphenoidal convolu-
tion; but, whereas the function of word-perception is limited to
the left hemisphere (in right-handed people), both hemispheres
participate in the perception and ideation of objects other than
words (see p. 110). From clinical and experimental observations
the physical bases of gustatory and olfactory perceptions have
been localized in the limbic lobes, and tactile in the post-central
convolutions (parietal association-area) of the two sides. Broadly
stated, the faculty of perception is localized in the association
areas of the two cerebral hemispheres.
The physiological difference between perception and ideation
is that percepts are aroused by stimulation of the corresponding
sensory end-organ, while zdeas are aroused by way of association-
fibres. Take, for example, the domain of vision. When I
perceive a brick, my occipital cortex is stimulated by way of the
retina; when I think of the brick, they are stimulated by way
of association-fibres, from the left temporal convolutions if I
hear a conversation about bricks, from the left angular gyrus
itself if I have seen the word “ brick ’’.
The actual mechanism of the process must be conceived as
the overcoming of resistance at certain synapses in the per-
* The angular gyrus was formerly considered the physical basis of visual
perception, but it has been shown that destruction of this convolution does
not cause ‘“‘ mind-blindness’”’ unless the underlying longitudinal fasciculi |
are also damaged (vide A. W. Campbell’s “‘ Localization of Cerebral
Function ’’).
32 MIND AND ITS DISORDERS
ceptual area concerned, the particular synapses varying from
percept to percept or from idea to idea, probably with protrusion
of certain gemmules and retraction of others.
SPACE-PERCEPTION.
Some psychologists believe the spatial idea to be innate. This
appears to be an unnecessary hypothesis. The new-born child
@)
CHES
SHOULDER
& TASTE
Fic. 5.
has but to experience movement of its own limbs, and of objects
in its environment, for the foundation of the extensive idea to
be already laid.
BINOCULAR VISION 33
The foundation being laid, development of the spatial idea
depends mainly upon our experience in the domains of vision,
touch, muscular sense and the static sense. It therefore becomes
our duty to ascertain in what manner these various senses
contribute to our idea of spatial extent.
Visual Space-Perception.
We have already stated that the retina varies all over its
surface in the mode of which it reacts to colour. This character-
istic gives each small portion of the retina its “local sign’”’, as it
has been called; and it is by means of these local signs that we
are enabled to recognize in which part of the visual field a given
object is situated. It has been suggested that the situation of
the object is not ascertained by movement of the eye, because
it is possible in a dark room to localize with exactitude an electric
spark of such brief duration as to give no time for eye-movement.
On the other hand, it has been observed, especially in young
babies, that stimulation of any portion of the retina by a light
produces a reflex movement of the eye, such as to bring the
image of the light to the yellow spot; and in the above experi-
ment a reflex eye-movement may occur after the disappearance
of the electric spark, this eye-movement contributing to the
knowledge of the situation of the spark. )
Although visual sensations aroused by objects in the external
world are produced by stimulation of the retina, we do not
localize an object giving rise to a visual image in the neighbour-
hood of the eye; we refer it to some situation in our environ-
ment. This feature has been magnified by some psychologists
into a special faculty of mind, “ eccentric projection ’’, whereby
our mental states are, as it were, thrown outwards into the
world of experience. Others again minimize the fact, asserting
that visual sensations are not associated with eye-sensations.
To the present writer introspection shows that visual sensa-
tions are associated with muscular sensations about the eye
and that these contribute considerably to the spatial idea. But
in whatever way we regard this mental state, there is no doubt
that we have a something-there feeling superadded to the crude
sensations and that we place in these ideational content, derived
from previous experience of similar sensations.
The two eyes regard the world from different points of view.
Consequently there is a difference between the images produced
upon their respective retine. This will be rendered evident if
the reader look over the edge of this book at the pattern of
4
34 MIND AND ITS DISORDERS
the carpet beyond and close alternately his right and left eyes.
The study of this fact, especially by the aid of the stereoscope,
throws much light on the psychology of perception.
Now although there is a different picture for each eye, we do not
experience two percepts, but one. There is a tendency to com-
bine any number of sensations given in consciousness into one
idea, and this tendency, which is known as the “ unity of idea-
tion ’’, may be shown by means of the stereoscope to be very
strong. For example, if there are placed in the stereoscope two
circles of slightly different diameter, one for each eye, we see one
circle of medium size. If instead of the circles there are two
horizontal lines, one for each eye, and one slightly above the
level of the other, the two lines fuse into one, midway between
the levels of the original two.
But, as we have already seen, not all combinations of sensa-
tions will fuse to form a single idea. If, for example, a slide
ihe Sita eae
Hic; 0:
similar to Fig. 6 be placed in the stereoscope, we do not see a
solid cross, but we see one of the lines crossing the other and
obliterating it at the point of intersection.
Fig. 7 gives a most puzzling result. Far from giving an
unitary percept, the different parts of the letters keep chasing
M W
FIG. 7.
each other out of the field. These are examples of “ideational
rivalry ”’.
We now proceed to the stereoscopic figures, which show how
binocular vision gives the idea of depth.
eo @ e @
OT
© e @
Fic. 8.
In Fig. 8 we see two dots, the right being more distant than
the left.
STEREOSCOPIC EXPERIMENTS B5
Fig. 9 is seen as a single line, with the upper end nearer to the
observer than the lower.
Fic. 9.
Fig. Io is seen as two circles, one in the middle of the other,
but nearer to the observer. In other words, it appears as a
truncated cone viewed from above.
O ©
Hite roe
Fig. 10A appears as a hollow truncated cone viewed from
below.
Q) ©
FIG. {IOA,
36 MIND AND ITS DISORDERS
Fig. II appears as one line curved toward the observer as in
looking down on an old-fashioned croquet-hoop.
In considering these various results it will be seen that there
is a tendency on the part of the organism to attach ideational
OT Geen Te
content to these groupings of sensation. If we place two marbles
horizontally in front of the eyes in such a way that the right
marble is farther off than the left, we have the conditions of
Fig. 8, the marbles appearing when viewed with the left eye to
BiG et?2,
be closer together than when viewed with the right; and we
have the conditions of Fig. 9 if the upper end of a stick be tilted
towards the observer. To the left eye it will appear to lean
to the right, and to the right eye to lean to the left.
SIMPLE PERCEPTUAL EXPERIENCES ay!
On the other hand, conditions never occur in the world of
perceptual experience in which an object appears to one eye to
be horizontal and to the other vertical: hence, we are unable to
combine the images of Fig. 6 or Fig. 7 into a single percept.
The tendency to attach ideational content to images is further
illustrated by some of the geometrical illusions. The angles of
perceptual experience are for the most part right angles; there
is consequently a tendency to assimilate all angles to a right
angle and hence to overestimate acute angles and to under-
estimate obtuse angles. When looked at with one eye, so as to
eliminate the true perception of depth gained by binocular vision,
Fig. 12 appears as a vertical line in the plane of the paper crossed
at right angles by a line passing through the plane of the paper,
especially if an extremity of the latter line be fixated.
The illusions in the following figures are adduced to illustrate
the part played by muscular sensation in the estimation of space.
Fic. 13.
Although a and 0b are the same length, } looks longer than a ;
the interpretation being that there is more muscular effort
required to carry the eye along 0, with all its interruptions, than
along the uninterrupted a. The same explanation applies to
the illusions in Fig. 14.
FIG. 14.
In Fig. 15 the horizontal and vertical lines are of equal length,
but the vertical line appears the longer because there is more
Fic. 15.
musculature brought into play in moving the eyes up and down
than in moving them laterally. Similarly, although the lines
38 MIND AND ITS DISORDERS
are exactly bisected, the upper half of the vertical line appears
longer than the lower half, because the muscles which move
the eye upwards.are not as well developed as those which move
it downward. Looked at with one eye, the outer half of the
horizontal line appears longer than the inner half, because the
external rectus is not so well developed as the internal rectus,
and therefore more effort is required to move the eye outward
than to move it inward.
The general conclusion from all these otperinen is that we
tend to attach to any group of sensations the content of some
idea, which has resulted from our experience of “‘ things ”’ as they
are usually presented to us.
There is yet one more illusion of the greatest interest which
demands our attention, as illustrating this point and also the effect
+ ++
+ ++
After-images of a right-angled cross. Perspective of a right-angled cross.
Fic. 16. PiGe 7.
of muscular movement in determining the nature of our per-
ceptions. Let the reader obtain an after-image of a right-angled
cross placed horizontally in front of the eyes. He will find that
the shape of the after-image is changed as shown in the accom-
panying diagram (Fig. 16), when he turns his eyes upward or
downward to the right or left. The explanation of this illusion
depends upon the perspective of a right-angled cross. If a real
cross be situated in the four corners of the visual field, it gives the
appearance represented in Fig. 17.
Now “the brain” has nothing to do with after-images; it
simply endows the sensations which it experiences with idea-
tional content; and “ the brain’s”’ experience is that a line, in
any of the four corners of the field of vision, which projects a
ESTIMATION OF DISTANCE 39
horizontal image on the retina, is not horizontal but tilted away
from the centre, as in Fig. 17. Hence results the torsion of the
horizontal line in the after-image of the right-angled cross. The
reader may convince himself of this torsion by facing one of the
walls of his room and looking upward to the right and left at
the line formed by the junction of wall and ceiling, and of wall
and floor.
This furnishes additional evidence of the tendency to attach
ideational content to sensations. It is also an illustration of the
fact that ideas may be altered by the addition of movement-
sensation to the content of consciousness.
We have seen that binocular vision plays a large part in the
estimation of distance. Muscular sensations caused by the effort
of convergence also contribute very materially to the spatial
idea. We are helped, too, by noting the amount of effort at
accommodation, the amount of eye-movement required to pass
several objects in review, the relative size of objects and the
relations of their bases. Other indications of distance are
uniformity and paleness of colouring, and the indistinctness of
boundary lines,
Cutaneous Space-Perception.
It has been mentioned that the skin, on examination, presents
areas of sensitivity to pressure, pain, warmth and cold. Now if
we were to draw up a map of the whole of the cutaneous sur-
face, a map based upon the distribution of these various sensi-
tive areas, we would find that no two parts of the map exactly
resemble one another. In other words, every portion of skin
has its local characteristics; and it is by means of these local
characteristics that we are enabled to determine the portion of
skin stimulated at any time. We localize cutaneous sensations
by means of their “local sign’’, in the same way as we localize
retinal sensations by means of their “ local sign”’.
We are not always quite accurate, however, in the localization
of a cutaneous sensation. For example, stimuli are not well
localized in the long axis of a limb, and in transverse localization
there is less accuracy on the outer than on the inner side. There
is also a large amount of error in parts of the skin which one
does not see, e.g., the middle of the back.
All parts of the skin are not equally capable of fecling as
double the stimulus given by a pair of compass-points. In some
parts the two points may give rise to one sensation, in other
parts to two. For example, at the tips of the fingers the two
40 MIND AND ITS DISORDERS
points can be distinguished when they are but two millimetres
apart, but in the middle of the back they are apprehended as
one stimulus if they are less than 60 millimetres apart.
Articular Space-Perception.
It has been shown by Goldscheider that our perception of
the position, attitude and movement of our limbs is dependent
on sensations arising in the articular surfaces of their joints;
since articular anesthesia, artificially induced by faradism or
other means, almost completely abolishes such perception. The
muscular sense, which hitherto has been credited with this
function, has very little to do with it; the function of the mus-
cular sense appears to be almost solely the appreciation of weight.
The greater the velocity of movement of a limb, the smaller
is the movement which can be perceived. The following table,
quoted from E. W. Scripture, gives the just-perceptible move-
ment around the various joints for the greatest velocity obtain-
able without jarring. The figures indicate degrees:
Second interphalangeal .. os! .. 1:03 10°20
First interphalangeal me ey «O92 ee
Metacarpo-phalangeal te ws <i 0-347 ,, Ones
Wrist re ae bia a -«) 0°20 Goes
Elbow ae oe phe “iP 7s) O40 eae
Shoulder ie ex a ie oe) O92 57a
im bye sr ra fs oe de .« 0°50 70-90
Ankle e ae “ <% oe =k" E5 po kee
Static Space-Perception.
All the above forms of space-perception contribute to the
knowledge of the position of parts of the body; but we are
provided with yet another sense, by which we are enabled
motorially to orientate the whole body. The labyrinth, con-
sisting of the otolith organ and the semicircular canals, is an
arrangement by which we become aware of change of position or
change of movement of the head, and therefore of the whole
body. It is owing to changes of pressure of the labyrinthine
fluid and the otoliths against the walls of the labyrinth that we
feel the rolling of a ship or the starting of a lift.
It has been found that, when a person is placed in a closed
chamber capable of being rotated on a vertical axis, he ex-
periences a sensation of being rotated only at the beginning of
rotation or during alteration of the velocity of rotation. As __
long as the velocity remains constant the chamber appears to
SPACE-PERCEPTION AI
him to be still; but when the rotation ceases or the speed is
decreased, he feels as if he were being rotated even more strongly
in the opposite direction. He can then demonstrate to himself in
the following way that the sense-organ by which he experiences
this sensation is within the head. If he bend his head forward,
the axis of rotation appears to bend forward too; and if he bend
the head sideways at a right angle, as if to rest it on one shoulder,
he feels as if he were rotating on a horizontal axis parallel to the
line of the shoulders. A patient with both labyrinths destroyed
has no perception of space in the dark; so much so that, if he
lie on the floor, he is unable to rise.
It has further been shown that the labyrinth is the receptive
organ for the reflex tonic contraction of the muscles of the body,
whereby it is maintained in any given attitude. As you sit
reading these pages, without any effort on your part the reflex
tone of your muscles maintains your body in an attitude entirely
different from that of a corpse placed in the same position,
whose toneless muscles would allow the various parts of the body
to succumb to the influence of gravity. Ewald has shown that
each labyrinth maintains the tone of the muscles of the same
side of the body, especially those of the neck and trunk, and the
extensors and abductors of the limbs. As Sherrington remarks
in his book “On the Integrative Action of the Nervous System”,
the effect of the “ knock-out ’’ blow on the point of the chin in
reducing a vigorous athlete to a toneless mass of flesh, whose
weight alone determines its attitude, is due to concussion of
the labyrinths. But this is a digression. So far as space-per-
ception is concerned, the labyrinth serves to indicate to us
changes in position of the body as a whole.
Auditory Space-Perception.
The localization of sound is much less accurate than that of
cutaneous and retinal stimuli. It is assisted by movements of
the head; but, even if the head be held perfectly still, we are
able to estimate the direction of a sound with a fair degree of
accuracy.
Under experimental conditions, it has been shown that sounds
are best localized when they are on the same level as the ears.
There is no confusion, as a rule, between right and left; but
mistakes occur in estimating whether a sound is in front or
behind. Localization is rather more accurate in front than
behind. It appears probable that sound is localized by means
of pressure stimuli communicated to the hairs of the pinna,
42 MIND AND ITS DISORDERS
since localization is very inaccurate if the pinne be strapped
back to the side of the head or an obstacle to sound be tied to
each side of the head in front of the pinna.
TIME-PERCEPTION.
The study of auditory perception throws light not so much
on our ideas of space as on those of time.
When listening to music, we find that it is arranged according
to a certain time or rhythm. Similarly when we listen to a
series of monotonous sounds, they appear to arrange themselves
in a certain rhythm. If, for example, we listen to the clicks of
a metronome, they seem to fall into pairs or threes, or into pairs
of twos or threes; or they may be arranged thus:
or even thus:
Fic. 19.
If we listen to a metronome in some such way as this and,
without counting, endeavour to discover how large a group can
be apprehended as a single idea, we find that under certain cir-
cumstances an unitary idea can be formed consisting of as many
as forty-eight clicks, provided they succeed each other with
sufficient rapidity, the whole series occupying less than twelve
seconds. In this manner we find that our maximum perceptual
unit of time is about twelve seconds.
If at any time we endeavour to think of the present moment
in contradistinction to the past or future we find that it is gone
before we have had time to think. The present is always im-
measurably short; it is indeed nothing but a moving boundary-
line separating the past from the future. As a matter of experi-
ence we include in our practical cognition of the present a short
period of immediate past. The existing unit of time, as thus
conceived, has received the name of “‘ the specious present ”’
(James), and the metronome has taught us that such an unit may
TIME-PERCEPTION 43
be as long as twelve or even fourteen seconds. These units are
not separate from one another, but perpetually and constantly
overlap.
If, when we are engaged in conversation, the clock should
happen to strike and occupy in striking less than one perceptual
unit of time, we can usually say how many strokes occurred
without having counted them or even attended to them; but
we are unable to do this if the striking has occupied more than
one perceptual unit of time, 7.e., more than twelve seconds.
Indeed it sometimes happens under these circumstances that
a person present remarks “‘ That clock only struck nine ’’ when
the clock struck eleven. This affords an excellent practical
illustration of the “‘ perceptual unit of time ”’. »
Inasmuch as we are unable to give a name to each such per-
ceptual unit, any given unit is identified with some incident
(psychologically speaking, with some percept). In the absence
of any percept of greater interest, we fix upon the fact that the
hands of the clock point in certain directions. In this latter
case the time-percept is clearly identified with a space-percept.
When a mother tells us that a certain event took place “ the
year that Willie was born”’, she is making an abstraction from
the Willie’s-birth idea, the temporal relations of a percept being
an essential part of the percept itself. Similarly the temporal
relations of an idea are an essential part of the idea. In the case
of a percept, there is always a feeling of ‘‘ now-ness ’’; and in the
case of an idea, the revival of a specific percept, there is a feeling
of “then-ness’’. The Willie’s-birth idea is incomplete if the
feeling of “‘ then-ness”’ be abstracted from it, if temporal rela-
tions be absent from the ideational content. Nowadays the War
serves as a temporal point d’appu for everybody.
This is one way in which an idea differs from a percept. An-
other is that a perceptual image is clear and strong, whereas
an ideational image, at least with most people, is indistinct and
faint; and a third is that more effort of attention is required
to obtain an ideational image than a perceptual one. It is
much easier to see a dog than to picture (visualize) one.
CONCEPTION.
_ When from a number of percepts or ideas an abstraction of
some quality or series of qualities is made and the qualities are
recombined, the result is a concept. In this sense the colour
“orange ’’ is a concept. The colour of the fruit is abstracted
from a large number of orange-ideas, and the result of the
44 MIND AND ITS DISORDERS.
recombination of these colours is the concept of the colour
“orange ’’: and if, from any number of orange-ideas we abstract
all the qualities—the yellowness, roundness, sweetness, acidity,
odour, coldness, softness etc., and recombine them, we have as
a result a conceptual orange. Observe that an orange idea is
the revived percept of a particular orange, and that an orange
concept is a recombination of the qualities of a large number of
revived orange percepts.
It will also be noticed that the feeling of past time, the feeling
of ‘‘ then-ness ”’ as we have called it, is not such an essential part
of a concept as it is of anidea. This must not be construed into
meaning that the absence of the feeling of “ then-ness ”’ is an
essential attribute of a concept. The conception of concrete
things is very closely related to ideation and therefore is fre-
quently associated with a feeling of past time. When I form a
concept from the various oranges which I have seen growing on
the trees in Italy, the feeling of “‘ then-ness ”’ is insistent.
Since conception is the abstraction and recombination of the
qualities of a number of ideas, such abstractions as truth, virtue,
health, happiness and honesty must be regarded as concepts.
Irom such abstractions the feeling of past time is usually absent.
If we abstract from our total number of ideas their spatial
qualities and recombine them, we have as a result “‘ conceptual
Space ’’; and if we abstract their temporal qualities and recom-
bine them, we have as a result “conceptual Time’”’. ‘“‘ Bound-
less Space ’’ and “‘ Eternity’ are examples of conceptual Space
and conceptual Time.
IDEATIONAL TYPE (OFTEN CALLED MEMORY-TYPE).
We have seen that the idea of an object is made up of sensa-
tions derived from various sense-modalities, visual, auditory,
tactual, olfactory, gustatory and kinesthetic, as well as of
sensations connected with the name of the object; and these
again may be visual, auditory or kinesthetic (muscular sensa-
tions connected with the pronunciation of the name). Some
of them play a much greater part in the idea of an object than
others; and the particular sense-modality which plays the greater
part varies in different individuals. If a person’s idea of an
orange is usually visual, his ideational type is visual; if olfactory,
then his ideational type is olfactory; if he thinks of an orange
in the terms of the written or printed word “ orange ’’, his idea-
tional type is verbal-visual; if he thinks of it in terms of the
sound of the spoken word “‘orange’’, his ideation is of the
IDEATIONAL TYPES 45
verbal-auditory type; and if he thinks of it in terms of the
‘ kinesthetic equivalent’’, the word “‘orange’’, as it feels to
him in his mouth when he says it, his ideation is of a verbal-
motor type.
The ideational type of most people is a combination of the
above, with the “‘ visual’’ predominating. Next in order comes
the verbal-motor type. Scientific men are as a rule bad visuals,
because their thought is so much engaged in concepts and other
abstractions. The author’s ideational type has quite distinctly
changed from the visual to the verbal-motor. In trying to court
sleep by the old device of watching sheep jump over a gate, the
sheep and the gate used to be quite clear and distinct; but now
it is quite impossible to see them. A faint outline of the middle
of the gate may occasionally appear, but the sheep refuse to
make their appearance.
In order to prevent misconception it ought to be said, by
way of conclusion, that the ideational type of a person appears
to have no psychiatric importance.
UNCONSCIOUS PERCEPTS.
The conclusions of this chapter, as of the last, are the results
of introspection and the subject-matter is a study of perceptual
and ideational processes as they occur in phenomenal conscious-
ness, but attention must again be directed to the unconscious.
We have unconscious percepts, unavailable for introspection,
as well as unconscious sensations; ideational content is uncon-
sciously placed in such crude unconscious sensations as were
mentioned at the end of the last chapter and percepts are thus
formed unconsciously. If the clock in my room ceases to tick
I look at it immediately to see what is amiss; thus showing that,
although the tick was unnoticed, it was noticed in some uncon-
scious way. A conversation beneath my window passes un-
observed, but it is possible that it might be recalled under the
influence of hypnotism. As you walk along a street you do not
heed the touch of the many people who brush past; but, if you
find on return that your watch has been stolen, you can probably
name the very spot where it was taken and recall a host of
hitherto unnoticed incidents that occurred there.
In psycho-analysis it is a common experience for the patient
to dream of some article, figure or design for which he can give
no explanation until he suddenly discovers in the analyst’s con-
sulting-room something which he had never consciously noticed
before although it has formed the item in his dream. A patient
46 MIND AND ITS DISORDERS
of mine dreamed of a certain parcel, of which he could give
every detail, including the way in which the knots in the string
were tied. We could make nothing of it; but, on rising to
depart, he suddenly exclaimed, “ Why, that’s the parcel in
my dream !’’ A small brown-paper parcel had been lying on
a shelf in my room for a couple of days, and his observation of
the knots was correct in every particular, yet he had never
consciously noticed the parcel before. This is not an unusual
experience; it is common. .
In this connection the post-hypnotic appreciation of time is
of interest. Delbceuf, Milne Bramwell and others have suggested
to patients under hypnosis that they would perform a given
act, ¢.g., make a cross on a piece of paper, after a given interval,
say, 3,400 minutes. This would be long after the hypnotic
séance was over. In almost every case the suggestion was carried
out impulsively at the correct time, without the patient knowing
why the act was performed.
There are certain observations which show that the initial
stages of normal perception take place unconsciously and that
the neurons concerned take an appreciable time to respond to
a stimulus. For example, it sometimes happens to an ento-
mologist, as he creeps along the side of the wall examining every
inch for a specimen of a certain butterfly, that he suddenly
realizes that he passed one four or five yards back; he returns
and finds it at the very spot where he expected to do so. In
this case the neural process is unconscious right up to the moment
of perception.
The reason for attaching importance to these unconscious
processes will appear later.
CHAPTER IV.
ASSOCIATION OF IDEAS.
IDEAS have been distinguished as simple and compound. When
I think of a brick, I have a simple idea; when I think of a house,
I have a compound idea comprising a number of brick-ideas,
window-ideas etc.; and when I think of a village, I have a com-
pound idea comprising a number of house-ideas. Now we have
already observed that the simple idea never occurs in actual
experience. <A brick is always perceived in connection with its
temporal and spatial surroundings; and when a brick is recalled
in ideation, ideas of other objects in spatial and temporal relation-
ship with the brick tend to be recalled with it. If the qualities
of the brick-idea be abstracted, they tend to become attached
to other ideas with different temporal and spatial surroundings.
For example, the redness of the brick may recall the redness
of an omnibus going to the City.
These are examples of the “ association of ideas’’, and such
associations have been classified as follows:
Associations by similarity.
Associations by contiguity—
(a) In space.
; simultaneous associations.
(>) In time te
successive associations.
An ordinary train of thought depends on the association of
ideas. If I think of having attended a certain concert, I perhaps
recall one of the songs which was about a bird; a similarity
association may cause me to think of birds at the Zoological
Gardens; a contiguity association arouses the idea of a friend
who accompanied me on my last visit to the Gardens; a simi-
larity association arouses the idea of Sherlock Holmes, and I
think of crime etc. But why, instead of this train of thought,
do I not form a continuous series of temporal-contiguity associa-
tions and think of the friend with whom I walked home after the
concert, of the letters I read when I entered the house, of my
47
48 MIND AND ITS DISORDERS
breakfast next morning and so on, by a process which has been
termed ‘‘ impartial redintegration ’’ ? In other words, what is
it which determines the association of one idea rather than
another with the idea already in consciousness ? This question
has been answered by reference to experiments with the “ memory
apparatus ”’. |
The memory apparatus consists of an upright board with a
couple of rectangular apertures side by side, through which
pairs of cards may be exposed for short periods of time. In
working with it the observer sits opposite the windows of the
board while the experimenter works the cards. A_ typical
experiment is carried out somewhat as follows: There are two
series of cards for each window: one series is coloured, the other
is white, with a letter of the alphabet printed on each card.
Pairs of cards are presented to the observer’s gaze, é.g. :
Red
Purple
Yellow
Green
Red
Brown
Yellow
Violet
Green
ORORMK DOH Ss
If a number of such pairs be presented to the observer and
single members of the series be subsequently given for him to
name the association he has formed with each of them, it is
found that the association of one idea with another depends on:
(1) The frequency and (2) the recency of their previous connec-
tion, (3) the relative vividness of the previously connected ideas
and consequently the degree of attention aroused by them and
(4) the relative position in the series of the previously connected
ideas; this depends also upon the degree of attention aroused.
For example, in the above series it is found that the tendency
to associate yellow with Q is strong on account of the frequency
of the connection; green is associated with S rather than D,
because the S-green connection is more recent; red is associated
with M rather than Y, because of the prominent position of the
M-red association (first); the L-brown association is a strong one,
because of the vividness of the L-impression, the L arrests the
attention. These laws are verified in actual experimental work
by using a large number of such pair-series with a large number
of observers and noting the frequency of right and wrong answers.
RECOGNITION AND MEMORY 49
This is necessitated by the fact that no mind is a tabula rasa,
for everybody has had vivid experiences peculiar to himself
which may cause deviation from the above rules. For example,
the red-Y association of our series might well be more insistent
than the red-M one in a soldier whose war experiences have led
him to associate red with blood and Y with Ypres. |
In applying these rules to the study of an ordinary train of
thought it must not be forgotten that the vividness of an im-
pression may be enhanced by the interest which attaches to it;
in other words, by the attention paid to it. But for this fact,
a logical train of thought would be an impossibility; all trains of
ideas would follow a scatter-brained course, as in the example
given above.
It will readily be appreciated that in everyday mental life there
are times when these laws conflict with one another, some com-
bining to encourage one association and some another; so that
the particular idea which comes into consciousness is that which
—on balance—an individual's experiences favour most, especially
those to which the greatest affect is or was or ought to have
been attached.
COGNITION, RECOGNITION, MEMORY AND IMAGINATION.
The simplest example of association by similarity is the
cognition or direct apprehension of an object. When I see a
hat, its shape at once revives the concept “‘ hat ’’, and the article
is at once cognized as a hat. When I look inside the hat and
observe the initials ‘““ W. H. B. S.’’, I recognize the hat as mine.
Recognition then is a simple example of association by conti-
guity; but no sharp line can be drawn between cognition and
recognition. When I turn a corner of the street and meet my
friend Brown, it is difficult to decide whether I cognize him
as Brown or recognize the object, which I have cognized as a
man, as Brown, by the contiguity association of the familiar
face with the man. Instances of recognition of this latter class
(recognizing Brown) have been called “‘ immediate recognition ”’
in contradistinction to those of the former class (the recognition
of the hat) which have been called ‘‘ mediate recognition ”’.
Mediate recognition is in reality an “‘ association of percepts ”’.
The process of recognition consists of three part-processes:
firstly, there is a percept; secondly, the percept calls up by
association secondary ideas of such percept having been pre-
viously experienced in different temporal and spatial surround-
ings; and, thirdly, there is a feeling of familiarity dependent, as
4
50 MIND AND ITS DISORDERS
we shall see later, upon muscular and other organic sensations
reflexly aroused.
Memory differs from recognition in that the first part-process
is the vevival of a percept or the presentation of an zdea. If,
in the above analysis of recognition, the word “idea ”’ be sub-
stituted for “ percept ’’, we have an analysis of memory into its
part-processes. When I think of some past incident, there is a
faint image of the incident (not necessarily a visual image);
there is a feeling of the image having occurred previously and an
accompanying emotional tone of familiarity. The image arising
under these circumstances has been called the ““ memory-image ”’ ;
all revived percepts are in reality memory-images. The form of
memory, corresponding to mediate recognition and dependent
on the association of ideas, is called “‘ associative memory ”’.
Memory then stands in the same relationship to recognition as
ideation stands to perception.
When we tvy to remember something which does not easily
come to mind, we endeavour to find associations. If, for ex-
ample, we wish to remember the name of a patient, we pass his
symptoms in review, try to visualize him, think of the town in
which he lived—if possible—and of the name of his doctor, and
perhaps we go through the alphabet in order to see which letters
arouse an emotional tone of familiarity. Ultimately we may
discover some association which recalls the name. On the other
hand, we may not, and we fail in our quest.
This brings us to the fact that forgetting is almost as common
as remembering, and must therefore be considered as a normal
mental function. It raises the question, ‘““ Why do we forget ?”’
whose answer is found by asking another question—‘‘ What do
we forget ?’”’ This has been answered by the method of psycho-
analysis, which is described in a later chapter. Psycho-analytic
investigation has revealed that anything forgotten has invariably
some unpleasant unconscious association. This does not usually
mean that the thing itself is unpleasant. For example, a school-
boy is asked by his mother to bring home a cake. He buys it,
but unintentionally leaves it in the train or bus; not because he
does not like cake, but because he has an objection (conscious or
unconscious) to carrying paper parcels. The following instance
occurred to the writer: He had accepted an invitation to dinner
and was obsessed by the fear that he would forget it, so much so
that he was careful to enter the engagement in every diary and
on every almanac he had. The day arrived, and the engagement
was forgotten. Subsequent analysis of the incident reminded
FORGETTING 51
him: that his would-be host, a charming person who willingly
forgave the misdeed, had originally been introduced by a “ friend ”’
who had proved false. The unconscious mind was trying for a
whole week to assert itself, and in the end succeeded. By a
similar mechanism, although we never forget the death of a dear
friend or relation, we do forget a host of minor events which
occurred about the same time, whose recall would tend by the
association of ideas to remind us of the painful incident and to
revive our grief. Our conclusion is, then, that forgetting is a
protective mechanism whereby the mind is shielded from un-
pleasant memories.
This mechanism undoubtedly plays an important part in
determining our amnesia for the first four or five years of life.
As we grow up, the ideas of having appeared naked before others,
of having been bathed and handled by others, of having been
cleansed after defecation, and so forth, become unacceptable to
phenomenal consciousness and they are forgotten. As we shall
see later, however, they are not lost, for infantile memories can
often be recovered by psycho-analysis or hypnotism; they are
merely repressed into the unconscious.
Another possible reason why early infancy is not remembered
is a physical one, viz., that many of the central association
neurons are not completely myelinized until four years of age
(Flechsig), and are therefore functionless.
The psychology of failure in recognition is parallel with that
of forgetting. We readily recognize a former patient, even after
many years, in whose case we were brilliantly successful in
diagnosis or treatment, and even those with whom we failed but
gained knowledge thereby; but when we meet a former patient
in whose case we failed and yet gained no knowledge thereby,
he may appear to be a total stranger.
Imagination bears the same relationship to recognition and
memory as conception bears to perception and ideation. When
we read an account of the upper reaches of the Amazon, we
imagine the scene by the associative combination of various
concepts of forests, rivers, men of colour etc., with various ideas
of South American animals and plants derived from descriptions,
pictures, museums, zoological and botanical gardens. The scene
is imagined by the associative combination of these into a new
concept.
There are two varieties of imagination, viz., reproductive and
constructive. They differ in the first part of the process. The
above is an example of “‘ reproductive imagination ’’. Firstly,
52 MIND AND ITS DISORDERS
there is a percept (the printed pages of the book describing the
scene) and secondly, the percept calls up various concepts and
ideas, abstractions from which recombine into a new concept.
If, instead of the primary perception, we have an associatively
aroused idea, we have an example of “‘ constructive imagina-
tion’’. This is the process which stands the poet, the novelist
and the inventor in good stead. A®sop’s fables, Jules Verne’s
stories, Coleridge’s ‘‘ Ancient Mariner”’ and the invention of the
printing-press and the steam-engine are all examples of con-
structive imagination.
JUDGMENT AND REASONING.
A judgment is formed when an abstraction is made from any
percept, idea or concept, and the abstraction recombined or
associated with the primary percept, idea or concept. In other
words, a judgment is an association after disjunction. When we
think of gold being yellow, we abstract the yellowness quality
from the gold-concept and reassociate the yellowness with the
gold.
A judgment is therefore nothing more than a special form of
association; the yellowness is merely associated with the gold
instead of with daffodils, the skin of a Chinaman or what not.
The verbal replica of a judgment is a proposition, 1.e., a
sentence in which a predicate is affirmed or denied of a subject,
a sentence in which “ it is asserted that some given subject does
or does not possess some attribute, or that some attribute is or
is not conjoined with some other attribute’ (J. S. Mill). The
proposition corresponding to the above judgment is “ Gold is
yellow ”’.
Reasoning consists of a series of judgments (verbally, a series
of propositions) related to one another, the last term of the
series being a conclusion dependent, rightly or wrongly, upon
the preceding judgments or propositions. The question of
legitimacy of inferences made during a train of reasoning belongs
to the art of logic, as also does the discrimination between true
and false propositions. Logic teaches us how we ought to think;
psychology tells us how we do think.
Unconscious ASSOCIATIONS.
If the mind be allowed to wander without conscious direction
of the flow of thought, as, for example, during the act of going to
sleep, and the current of ideas be observed by introspection, it
UNCONSCIOUS ASSOCIATIONS 5
will be noticed that here and there an incomprehensible jump
occurs from one idea to another, apparently quite disconnected.
If now the subject, probably the reader, in a second somewhat
similar experiment, allows various associations to develop with
each of the two apparently disconnected ideas separately, he will
probably hit upon the connecting-link between the two, which
never entered consciousness in the original train of thought. The
- association of ideas was unconscious.
Another method of discovering unconscious associations is by
the word-association test, which consists of giving a series of
stimulus commonplace words to each of which the patient or
subject has to react by naming the first association or reaction-
word which occurs to his mind. The subject will occasionally
respond to a stimulus-word with a reaction-word having no
obvious connection with the former, and he may even remark,
“I do not know why I said that’”’. On closer investigation, it
is found that there is a connection, and that the lack of coherence
was only apparent. The connecting idea was unconscious.
Reference has already been made to the common difficulty of
remembering a name. Various efforts are made, but it is found
impossible voluntarily to recall it; but, perhaps long afterwards,
when one is thinking of something having no manifest connection
with it, the name suddenly forces itself upon consciousness. The
association of ideas in such a process is unconscious, and it is
only by subsequent analysis that an association is discovered
between the name and the content of consciousness preceding
the moment of recall.
Complexes.—Ideas are never isolated in the mind; they are
apt to cluster round some particular trend of thought tending to
emerge in some form of activity. Such a cluster is known as a
“ constellation of ideas’’. The individual is sometimes totally
unaware of some, or even all, of the ideas in such a group,
although they are in his own mind. They are repressed into the
unconscious, and can only be discovered by some process of
mental analysis. Such unconscious constellations are known as
“complexes ’’ and we shall have frequent occasion to refer to
them in later stages. The association of ideas plays an all-
important part in mental life and we shall find that complexes
play an enormous role in the mentation of both the sane and
the insane.
CEA Re ie yc
AFFECTION.
THE word “affection ’’ is used by psychologists to mean the
pleasant or unpleasant tone of feeling which accompanies
sensation.
Most persons find unsaturated and intermediate colours more
pleasant to look upon than saturated colours; with some ob-
servers the reverse is the case. Greys are more pleasant than
pure white or black. Tones are more pleasing than noises, and
tones of medium pitch than those of very high or very low pitch.
Odours of fruit and flowers are more agreeable than those of
decaying animal matter. Sweet and salt substances are generally
more acceptable to taste than sour and bitter. Moderate warmth
is more pleasant than extreme heat or cold. Painful sensations
are almost invariably associated with a tone of unpleasantness.
Sexual sensations are usually pleasant. Moderate muscular
exercise is pleasant, while excessive muscular exertion and
enforced rest are unpleasant; and, with regard to sensations in
general, it may be noted that weak stimuli are as a rule more
agreeable than strong ones.
Although sensations are commonly accompanied by a tone of
feeling, affection is not to be regarded as an attribute of sensa-
tion. Affection is, in its essence, a superadded mental state
of the individual who experiences a sensation. As I sit by the
fire on a frosty day the warmth seems to be in the skin, but the
pleasantness of the warmth is the way in which I experience it.
Moreover, sensation is more localized than affection. If I knock
my shin against a chair in the dark, the sensation is localized
in my shin; but the unpleasantness of the pain pervades the’
whole of consciousness. Again, a tone of feeling tends gradually
to disappear, to wear off, while the sensation remains practically
unaltered.
Sensation and affection differ in yet another way. If we.
attend to a sensation, it grows clearer and more intense. If
we attempt to attend to an affect, the tone of pleasantness or
unpleasantness at once disappears. This will be better under-
o4
AFFECTION 55
stood when we have considered the phenomena of attention. For
the present, it may be noted that attention to the tone of feeling
necessitates inattention to the sensation which gives rise to it.
As previously stated, sensation and affect cannot be divorced
from one another, and we shall soon learn that it is the all-
important affect which dominates our conduct through life.
The physical concomitants of affection have therefore been
studied and, as a result, it has been shown:
1. By the plethysmograph, that a positive tone of feeling
(pleasantness) is accompanied by an increase of bodily volume
(dilatation of arterioles) and a negative* tone (unpleasantness)
by a decrease (contraction of arterioles). The latter is possibly
due to adrenalin, since it has been ascertained by Cannon that
such emotions as pain, fear and anger are accompanied by an
increase of internal secretion by the adrenal bodies.
2. By the sphygmograph, that a positive tone is accompanied
by a decrease in pulse-frequency, a negative tone by an increase. T
Some psychologists measure the degree of an emotion by the
amount of increase of the pulse-rate, especially in response to
certain stimulus words. Indeed, the existence of an emotion is
sometimes detected by a change in the pulse-rate alone.
3. By the pneumograph, that a positive tone is accompanied
by deeper respiration, a negative by shallower.
4. By the dynamometer, that a positive tone is accompanied
by an increase of muscular power, a negative by a decrease. |
5. By the automatograph (a scientific form of planchette),
that a positive tone is accompanied by abduction of the arm, and
a negative by adduction.
6. By the galvanometer, that emotions alter the electrical
conductivity of the body.
These results indicate a general tendency on the part of the
organism to reach out towards the pleasant and to withdraw from
the unpleasant. A moment’s consideration will show that this
is the whole nature and purpose of affection; pleasing things
attract and unpleasing things repel the organism. In the scheme
of evolution, affection is the inevitable sequel to the development
* This statement is in accordance with German views. Titchener states
the contrary.
t Cannon has also determined an augmentation of the sugar content and
of the coagulability of the blood in unpleasant emotions, both originated
by enhanced adrenal activity. Although we are rather anticipating,
it may here be suggested that the greater production of sugar supplies the
muscles with energy required for defence or attack, and that the increased
coagulability of the blood is preparatory to the healing of possible wounds
in combat.
56 MIND AND ITS DISORDERS
of sensation and movement. It is the tone of pleasantness which
attracts the organism to its food and other objects necessary to
the maintenance of its life or to the perpetuation of its race. It
is the tone of unpleasantness which repels from danger. If a
race of hares should evolve which regarded the appearance of a
greyhound with indifference, that race would very shortly come
to an end. If a family of children were born who took pleasure
in sitting on the fire, they would not live to perpetuate their
species. And if a man develops a lasting revulsion from food, he
dies unless the natural laws of evolution are counteracted.
It has been observed that attention to an affection is an
impossibility, and this observation might lead to the inference
that introspection can render but little assistance in eluci-
dating its psychology. We have, however, been using the
phrase ‘‘ tone of feeling ’’ in discussing the nature of affection.
By retrospection, which differs but slightly from and is in many
cases the same thing as introspection, we find that the phrase
“ tone of feeling ’’ is wellfounded. The affective tone of pleasure
or pain is a feeling or sensation superadded to the sensation
which gives rise to it; and since we have found that sensations
arise from peripheral stimuli, it becomes our duty to look round
and see if we can discover any stimuli which may be regarded
as the cause of this superadded sensation.
The experimental results obtained in the investigation of
affective states by means of the plethysmograph, pneumograph,
automatograph etc., supply the required information. We find
that in affective states stimuli to muscular and circulatory
sensations are at work in divers parts of the body. The in-
ference is that these give the superadded sensations which con-
stitute the feelings of pleasure and pain. The dilatation of
arterioles, the increased pulse-frequency, the deepened respira-
tion and the arm abduction are motor phenomena which take
place involuntarily. Indeed, we should not have known that
they occurred but for experimental observation. They are,
therefore, to be regarded as reflexes.
From the above considerations, therefore, we learn that the
feelings of pleasure and pain are due to muscular and circulatory
sensations, which are nothing more than a complicated reflex
action, and that the intrinsic nature of these feelings has developed
as a natural sequel to the struggle for existence.
EMOTIONS | 57
EmoTIoNs, PAssions, Moops AND TEMPERAMENTS
(GENERICALLY TERMED AFFECTS).
The tone of feeling which attaches to a percept is of a much
more complex nature than that which attaches to a simple sensa-
tion, and it has a very much larger number of varieties. These
are known as the emotions. An emotion is the tone of feeling
which attaches to a percept, idea or concept; and inasmuch as
the colour of the emotion differs with almost every possible
percept, idea and concept of things, people, incidents and situa-
tions, a satisfactory classification of the emotions is practically
an impossibility. The feeling of attraction towards people and
things may take the form of interest, familiarity, intimacy,
reverence or love. Repulsion may take the form of dislike,
disgust, antipathy, contempt, repugnance, disdain, hatred or
anger. Ideas of welfare may be associated with feelings of
satisfaction, gratitude, contentment, joy, hope or anticipation;
ideas of harm with feelings of sorrow, grief, dissatisfaction,
resignation, despair, fright or horror. If the ideas are of the
welfare or injury of others, we may have feelings of gratification,
gladness, envy, jealousy, regret, care orsympathy. Yet all these
take no account of such feelings as those of effort, misery, decision,
defiance, pride, shame and mirth. Indeed, every mental opera-
tion has its emotional element. Such processes as recognition,
comparison, discrimination, judgment and reasoning have a
characteristic feeling attached to each of them, and this should
not be omitted in a complete description of any of these processes.
In attempting a study of the emotions we are met with the
same difficulty as in the study of affection; the emotion is gone
as soon as attention is directed to it. By a careful series of
retrospections, however, we can arrive at the conclusion that
an emotion consists of a number of sensations and that these
sensations are derived from the activities of certain muscles
(voluntary and involuntary) and glands (sudorific, lachrymal,
intestinal etc.). The activities of involuntary muscles give rise
to certain circulatory changes, such as increased or diminished
frequency of the pulse, as well as to local flushings and pallors.*
* Sir Charles Sherrington has sought to exclude circulatory and other
visceral changes from the physical basis of emotion. Choosing a dog which
was especially liable to violent outbursts of rage, joy, disgust and other emo-
tions; by appropriate spinal and vagal transection he removed completely
all sensation from the viscera. Yet the dog continued to give evidence of
emotion by retraction of the upper lip, pressing backward of the ears,
growling etc. This experiment does not prove that visceral sensations,
58 MIND AND ITS DISORDERS
The more we investigate the matter, the more we become con-
vinced that these sensations are the very essence of emotion.
Let the reader conjure up some emotion and note the various
sensations which he experiences in connection therewith. Then
let him divest the emotional feeling of all these bodily sensations,
and he will find that there is no part of emotional feeling left.
The various activities which give rise to the emotions are also
responsible for their expression. The expression of an emotion
is that movement or complex of movements occurring in an
individual which indicates to others the nature of his emotion.
In the emotions accompanying pleasant ideas there is an
increase of muscular tone and power, with a tendency to abduc-
tion of the arms, a decrease of pulse-frequency with general
dilatation of the arterioles, and an increase of the frequency and
depth of respiration. In the emotions accompanying unpleasant
ideas we have the reverse bodily conditions. This much we have
already learned in our study of affection; but, in addition to these
physical signs, there are many others in the various emotions,
each complex of physical signs giving rise to that expression
which is characteristic of the particular emotion. In anger
there are contraction of the corrugatores superciliorum, fixation
of the gaze, dilatation of the nostrils, tightening of the lips,
grinding of the teeth, clenching of the fists, extension of the trunk
and flushing of the face. In disdain there is contraction of the
levator labii superioris aleque nasi. In fright the mouth and
eyes are widely opened, there are extension of the trunk and
limbs and pallor of the face. In suspicion there is rapid lateral
oscillation of the eyes. In dissent there is lateral nodding of the
head; in assent, antero-posterior nodding of the head.
It has been pointed out by Darwin and others that all these
apparently purposeless actions are the unconscious survivals of
actions which previously have been of conscious service to
ancestral organisms. For example, in anger the gaze would be
fixed upon a dangerous enemy, the fists clenched and the teeth
ground upon some portion of his flesh; the dilatation of the
nostrils would then become a necessity for breathing. The
disdainful contraction of the levator labii superioris aleeque nasi
is the uncovering of the canine tooth preparatory to biting the
as Sherrington suggests, contribute nothing to emotional feeling. The
dog expressed emotion by and experienced it from contraction of its facial
muscles, because spinal transection could not possibly interfere with these
facial reactions; but there is no proof that the emotional feeling of the dog
was not diminished by the removal of its visceral sensations.
PASSIONS, MOODS AND TEMPERAMENTS 59
object of disdain. Oscillation of the eyes in suspicion is the
search for anticipated danger. The lateral nodding of the head
in dissent is the survival of the movement with which the infant
refuses the proffered breast; while the nodding of assent is the
movement of acceptance of the breast. Fear, at least so far as
its physical signs are concerned, is exhausted anger or passion.
Emotional feelings, then, consist of a complex of sensations
arising from these various activities. According to this view
(the Lange-James theory) it is not the emotion which gives rise
to the expression, but the expression which gives rise to the
emotion. The truth of this assertion was appropriately referred
by Professor James to numerous actors, who were asked whether
they experienced the emotions which they portrayed upon the
stage. The best actors appear to be unanimous in the verdict
that they actually feel the emotion they portray, when they
are acting an emotional part well. The experiences of the audi-
ence are no less interesting. When a member of the audience
feels that he is being too much overcome by the sadness of the
situation on the stage, he extends the trunk, assumes a smile,
takes a deep breath and surreptitiously wipes away the starting
tear; by such means he dispels the emotion. And how often is
an ill-timed merriment suppressed by assuming the expression,
say, of attention. It requires, however, considerable effort to
subdue a strong emotion; for emotions have a tendency to
persist long after the ideas which aroused them have disappeared
from consciousness (inertia of emotion).
The conclusion is, therefore, that an emotion is a feeling com-
pounded of sensations which arise in consequence of complex
movements reflexly aroused by the situation (real or imaginary)
in which the individual is placed.
Many psychologists are unwilling to accept this theory, yet
they have failed to discover the fallacy of it, if one exists. The
best argument I know against it is that those patients who suffer
from certain organic diseases of the nervous system which induce
involuntary laughter are reported as stating that they do not
feel the emotion of laughter; but these reports are unaccom-
panied by any statement respecting other parts of the body.
It may well be that painful persistent laughter induces motor,
vasomotor and other reactions of annoyance elsewhere than in
the face.
Emotions have an inhibitory effect on the association of ideas
and retard this process, which inhibition psychiatrists have to
overcome in analyzing the mental life of a patient.
60 MIND AND ITS DISORDERS
Each emotion has its corresponding passion and mood, a
passion being an intense emotion of short duration, and a mood
a prolonged emotion of moderate intensity. Fury, anguish,
terror and hilarity are the passions corresponding respectively
to anger, sorrow, fear and joy; the corresponding moods are
respectively chagrin, gloom, anxiety and happiness.
Closely allied to the moods are the temperaments. For
practical purposes, a temperament is to be regarded as a mood
which lasts the greater part of a man’s life. It is a man’s tem-
perament which is mainly responsible for the nature of the
emotional tone aroused in him by any particular incident. The
same incident will arouse different emotions in different indi-
viduals. A similar incident will also induce different emotions
in the same individual at different times, according to his already
existing mood or emotion.
Four temperaments are recognized: the sanguine, the choleric,
the phlegmatic and the melancholic. The sanguine and the
choleric are the temperaments characterized by rapidity of
thought and ease of receptivity, the phlegmatic and melancholic
by slowness of thought and receptivity. The choleric and the
melancholic are characterized by greater depth of feeling than
the sanguine and the phlegmatic.
Temperaments.
Shallow Feeling. Deep Feeling.
Slow thought and re- © Phlegmatic Melancholic
ceptivity | |
2 (a
Quick thought and re- Sanguine | Choleric
ceptivity | |
THE PHYSICAL BASIS OF EMOTION.
There is evidence to show that the thalamic region plays an
important rdle in the development of an emotion reflexly aroused.
If a patient has a lesion of one optic thalamus, say the right,
and you tell him a joke, he smiles on the right side of the face
only; the smile does not occur on the left side. That this
paralysis is not due to a lesion of the cortex or pyramidal tract
is shown by the fact that the two sides of the face act equally
when he assumes a smile. If, on the other hand, the patient has
PHYSICAL BASIS OF EMOTION 61
a lesion of the right Rolandic area, he smiles equally on the two
sides in response to a joke; but an asswmed smile occurs on the
right side only, volitional action being paralyzed on the left side.
The observation of movements of expression occurring in the
limbs is a more difficult matter in paralyzed patients; the
physician has to rely upon an opportunity of watching the hand
when the patient yawns. In paralysis of the hand due to some
unilateral cortical lesion, the patient is unable to open the
affected hand voluntarily; but if he yawns, the hand opens
slightly. If, however, he has a lesion in the region of one optic
thalamus, he can open the opposite hand voluntarily; but it
does not always open involuntarily when he yawns. The con-
clusion to be drawn from these observations is that the tracts
subserving the motor element of emotion cross to the opposite
side of the spinal cord.
Now the only bundle which crosses from the mesencephalon
to the opposite side of the cord is the rubro-spinal bundle of
Monakow, that bundle which, as Held and Probst, and subse-
quently Buzzard and Collier, have shown, arises on the ventral
side of the red nucleus, decussates in Forel’s crossway with the
corresponding bundle of the opposite side and is traceable to
the region of the lateral tracts as far as the sacral region of the
spinal cord. It connects the opposite nucleus ruber with the
ventral horn of the cord. I submit, therefore, that Monakow’s
bundle subserves the function of the motor element of emotion.
We have also to consider the cortical portion of the system
of motor neurons subserving the function of emotion. For this
function a system of fibres is required to connect the cortex with
the nucleus ruber, and such a system has been described by
M. and Mme. Déjérine. The fibres originate from all parts of
the cortex, especially the parietal lobe. They skirt the thalamus
just above the radiations of the internal geniculate body, enter
into the formation of the tegmentum, and reach the red nucleus
at its antero-supero-external part. These fibres are to be
regarded as the upper segment of the emotional motor system.
Their intimate anatomical relationship with the thalamus easily
accounts for the fact that that structure has hitherto been regarded
as the physical basis of movements of expression.
More primitive emotions, however, appear to be aroused by
reflexes in lower levels of the nervous system. Goltz observed
signs of hunger in dogs from which he had removed the cerebral
hemispheres, and Sherrington, quoting Sternberg and Latzko,
observes that the crying of the young infant has been noticed
62 MIND AND ITS DISORDERS
we
in “‘hemicephalic’”’ (? anencephalic) children to be strong and
of the usual character. 7
Head and Holmes have shown that many crude sensations are
apprehended by the thalamus without reference to the cerebral
cortex and, moreover, that in lesions of the upper part of the
thalamus the affective tone attaching to these sensations is
increased. It would therefore appear that at this level there is
a nervous arc from the thalamus to the red nucleus subserving
the function of affective tone (in contradistinction to emotional
tone), an arc of thalamo-rubral fibres probably included in the
bundle of Meynert and under the tonic inhibitory control of
cortico-thalamic neurons. The increased tone of affection in
cases of tumor thalami would then be explained by the re-
moval of this inhibition, the cortico-thalamic fibres having been
destroyed by the lesion.
It is of considerable interest that the cortico-rubro- gia
motor system is the main representative of the pristine motor
tract, by which in the lower vertebrates all motor impulses are
transmitted. It has been demonstrated by Munzner and Wiener,
Boyce and Warrington, Edinger and others that the pyramidal
system of fibres does not exist in birds or in any of the lower
vertebrates. In these animals the motor tract consists of
cortico-thalamic and thalamo-spinal neurons only, the spinal
fibres occupying the same relative position as the direct and
crossed pyramidal system of mammals. In this connection
it will also be remembered that in man the pyramidal tract is
not completely myelinized until about the fifteenth month.
Professor James has indicated the close relationship subsisting
between emotions and instincts. They are both involuntary
motor responses to percepts and ideas, and the only difference
between them is that instincts bring the organism into more
practical relation with the object of the percept or idea. .Now
the lives of birds and lower vertebrates and the life of the human
infant until it is about fifteen months old are practically little
more than a mass of instinctive and emotional reactions; and it
is not surprising to find that such reactions are, among the higher
vertebrates, still dependent upon the functioning of the pristine
nervous system.
The neural process which takes place when an emotion occurs
is then as follows:
Starting from the stage at which a sensation is registered in
one of the projection areas or a percept or idea formed in one of
the association areas of the cortex, an impulse is transmitted to
REPRESSED EMOTIONS 63
the red nucleus by way of the cortico-rubral fibres, thence to the
large motor cells of the lowest level by way of Monakow’s rubro-
spinal (and presumably rubro-bulbar) fibres of the pristine motor
system, and thence to the muscles of expression. Contraction of
these muscles upon their spindles effects the transmission of
muscle-sensations to the cortex by way of the ordinary sensory
paths, and it is the particular combination of these sensations
among themselves and with vasomotor sensations, which deter-
mines the particular affective or emotional tone.
UNCONSCIOUS EMOTION.
It frequently happens, for reasons which will be set forth later,
that the individual fails to react in the above manner to this or
that experience. The emotion is then said to be “ repressed ’’.
The reaction, not having taken place, leaves a certain amount
of nervous energy (neurokyme) active, but ill-directed and
unconscious.
Every civilized being has innumerable selfish desires which he
is unwilling to admit even to himself; they are therefore repressed
into the unconscious. In terms of our theory, the subject
voluntarily inhibits his natural cortico-rubro-spinal reactions.
The most repressed of all desires are the sexual, and the result
is that the unconscious, though chock-full of emotions of all sorts,
is very largely sexual, and we shall find that these unconscious
sexual desires play a very large rOle in the production of many
symptoms and forms of mental disorder.
Whenever a situation or incident tends to arouse an emotion
which the subject does not wish to feel, such emotion is re-
pressed into the unconscious and replaced in consciousness by its
opposite. The old maid refuses to admit, even to herself, the
slightest trace of sexual passion; it is therefore repressed and
converted, in consciousness, into its opposite—prudery. A girl
falls in love with a man who gives not the slightest indication
that her love is reciprocated; she therefore represses her love
into the unconscious and replaces it in the conscious by its
opposite—hatred. Our brave soldiers in France almost daily
saw such appalling sights as the limbs of a comrade being hurtled
through the air by the explosion of a German shell. To react
to such an experience every time with the natural emotion of
horror would render trench-life intolerable; so the emotion was
repressed into the unconscious, and replaced in consciousness
by its opposite—laughter; and a side which did otherwise would
lose the war. Those who failed to react at all, who neither
64 MIND AND ITS DISORDERS
laughed nor acknowledged to themselves a feeling of horror
or fear, ultimately suffered from “ shell-shock’”’ in some form
or other. Their unexpended neurokyme became a pathogenic
force. It must be admitted that this is not a complete explana-
tion of “‘shell-shock”’, for psycho-analysis of these patients
reveals a much more deeply rooted complex which, in my ex-
perience, is invariably the same in every one of them.
Another important practical point about the psychology of
emotion is that it is possible for an affect to remain conscious
although the situation or idea which gave rise to it has been
repressed—become unconscious; the result being that the affect
remains unattached—floating free, so to speak, but ready to
attach itself to any or every passing incident; or the affect may
become permanently attached to some idea having little associa-
tion with that which originated the emotion, “ transference of
the affect’’.
Both of these principles are illustrated by the fear which
many women experience in the presence of a mouse or a cow.
The cow’s horns are penetrating objects, her teats are rather
obviously phallic in aspect, and the woman’s fear of a mouse is
due to the fact that it “ might run up her clothes’’. Now the
normal biological female affect towards the male organ is desire,
but social and moral tendencies lead to repression of this emotion
into the unconscious—its place in consciousness being taken by
its opposite, viz., fear. Not only so, but this fear becomes
dissociated from the idea of the male organ itself and becomes
attached to such remote symbols of it as a cow and a mouse.
The very strong objection which some people have to being in
the dark or to standing on a height is usually traceable to some
forgotten infantile experience, usually non-sexual, to which they
failed to react at the time. By psycho-analysis such infantile
memories may be revealed and revived in consciousness, with the
result that the fear is dispelled.
CHAPTER VI.
ACTION.
In this chapter we have to consider the psychical concomitants
of movements of the organism. There are four forms of action,
viz., reflex, instinctive, volitional and automatic.
REFLEXES.
Reflex actions are all carried out by the lowest level of the
nervous system, the level in which, to use the language of Dr.
Hughlings Jackson, muscles are first represented, and which
extends from the oculo-motor nuclei to the tip of the spinal
cord. Reflexes have no psychical concomitants; but, as we shall
see later, they frequently serve the purpose of arousing conscious-
ness by drawing our attention to a stimulus which might other-
wise pass unnoticed. Reflexes are developed in accordance
with the natural laws of evolution, which result in the survival
of the fittest. If ever there existed a race of men without
plantar reflexes, that race has long since died out from septicemia,
tetanus and other results of treading on sharp stones etc. If
ever there existed a race whose pupils did not react to light, that
race has been destroyed long ago by its enemies whose pupillary
reaction saved them from being blinded by the glare of the sun
during combat. Sir Charles Sherrington, by his experiments on
decerebrate cats and dogs, has taught us that many actions of
great complexity, which hitherto have been considered to be of
cerebral origin, are in reality of a reflex nature. For example,
stimulation of one pinna of a spinal cat induces movements of the
head and of all four limbs; while stimulation of one paw induces
reflex movements of all four limbs and, in the case of a forepaw,
of the head also. It is probable that even such a complex action
as the crying of a new-born infant may be purely reflex.
INSTINCTS.
Instinctive action differs from reflex action in that it has
psychical concomitants. It is practically perfect on the very
first attempt, although there has been no previous education
65 sy,
66 MIND AND ITS DISORDERS
in its performance, and it is of such a nature as to produce
certain ends without foresight of those ends. At least there is
no foresight on the first occasion of its accomplishment. A few
instances will make this clear.
Butterflies and moths invariably lay their eggs on or near the
leaves of the plant which is the natural food of their young.
These insects never knew their parents and they will never
know their children; the butterfly therefore has no means of
knowing what she is depositing when she lays her eggs near the
food-plant of her caterpillar. Why does she do so? It is
simply instinct; she cannot help it and the performance is known
as an instinctive act.
The first-year bird with a fertilized egg in her oviduct collects
roots, moss, hair and feathers, and builds herself a nest; yet she
can have.no idea that she is going to lay eggs therein; she has had
no previous experience of such a performance. The plover lays
her eggs in a ploughed field where they closely resemble the stones
and are hence easily overlooked by predatory youths, but she
has no means of knowing that her eggs will resemble stones.
Further, when she has laid her eggs, there seems to be no possi-
bility that she can have the remotest idea of their nature; yet
she sits, and sits, and sits upon them until they are hatched.
Why does the bird go through all this performance? Simply
because she cannot help it; it is the inborn way of the bird; it is
instinct. If evera bird existed that made no provision forits young,
its race has died out in accordance with the laws of evolution.
These are but a few examples, but it may be stated generally
that some of the lower mammals, all birds, all vertebrates and
perhaps all animals lower in the scale than birds, lead a purely
instinctive life. Voluntary action, presently to be described, is
peculiar to mammals.
This fact is of the greatest interest when it is correlated with
the anatomical differences, already mentioned in the chapter on
the emotions, between the motor nervous system of mammals
and that of birds and lower vertebrates. Mammals alone have
a pyramidal tract, subserving volition. We shall see later that
instinct is essentially the same thing as emotion; its physical
basis is therefore the same as that of emotion, viz., the cortico-
rubral system of neurons, which is the mammalian representa
tive of the pristine motor system of the bird.
Although mammals are endowed with a volitional motor
system as well as an instinctive, they are quite as full of instincts
as the lower vertebrates. Why does a cat run after a mouse?
INSTINCTIVE ACTION 67
Not because she is hungry and requires a meal, for she will run
after the mouse whether she is hungry or not. It is for the same
reason that many dogs will run after a bird; the likelihood of
the bird forming a meal for the dog is exceedingly small. It is
simply that these animals cannot help it; it is the instinct of
pursuit. Why does the mouse run away from the cat? Not
because it has any idea of death. Why does the Polar bear
deliberately expose herself to the danger in which she sees her
young ? Why does any animal seek its mate ? Why do many
animals crowd together in flocks or herds? Simply because
they cannot help it; it is their instinct.
Instincts, like reflexes, have developed according to the laws
of evolution. If ever there existed a species of swallow which
did not migrate for the winter months, it has long since died
out from the effects of cold; and if ever there existed a genus
of bird which did not make provision for its young and sit on its
eggs, that genus has in consequence ceased to exist. Instincts
are developed for the benefit of the race. Occasionally, however,
we come across an uncorrected instinct, as in the case of the
lemming, which periodically attempts to migrate in its thousands
from its native valleys in Norway to the long-submerged con-
tinent of Atlantis: the result is that thousands of these animals
are drowned in the sea, and their race runs the risk of becoming
extinct.
Man has been said to possess more instincts than any other
animal. Innumerable are the occasions when he acts as he does
for no other obvious reason than that he wishes so to act, the
real reason being unconscious and buried in the past history of
the race. Nevertheless, we shall find that these unconscious
desires are the driving force of the whole of mental life. They
constitute “ psychical energy ”’ or, as Jung has called it, “‘ horme”’.
Psycho-sexual energy is known as libido.
By the sixth week of life, eye movements are practically com-
plete, and a child will instinctively converge for near objects.
Passive attention develops, so that he will turn his head in the
direction of a sound and reach out towards an object. Tactual
space-perception, however, is yet incomplete, for at this age he
will perhaps reach for the moon.*
The seventh week is characterized for the development of the
smile. .
In the ninth week the instinct to handle objects is first observed,
and by the eleventh week movements, which have hitherto
* Some of these actions are possibly reflex.
68 MIND AND ITS DISORDERS
been apparently aimless, begin to assume a more purposeful
aspect.
The instinct to imitate sounds also makes its appearance about
this time. Surprise and fear begin to develop, especially fear of
change. This fear of change increases during the fourth month,
until, in the fifth, we find it crystallized into an instinctive
shrinking from strangers.
Laughter shows itself at the beginning of the fourth month.
During the fifth month the child develops the instinct to sit
up and, about the end of that month, to carry objects to the
mouth.
The idea of distance, which a chick demonstrates as soon as it
leaves the shell by pecking at morsels of food, does not appear
in the human infant until the sixth month of life. The instinct
to grasp objects appears in this month, but the child seems to
have no idea of letting objects go until two months later.
In the eighth month the child begins to take pleasure in
making a noise, an interesting instinct often preserved through
life. It will throw things on the floor for the pleasure of thus
making a noise.
The instinct of locomotion is usually first observed during the
tenth month; this is followed in the eleventh month by the
instinct to stand, the child constantly trying to get upon its
feet; and during the twelfth month this develops into the walking
instinct.
During the ninth month the instinctive basis of language
appears for the first time, and such sounds as “ kak-kak”’,
“ba-ba’’ and “da-da”’ are uttered. These repetitive sounds
have probably little or no meaning until about the fifteenth
month, when “ dada ”’ and ‘“‘ bow-wow ’’ are uttered in association
with the respective percepts ofa manandadog. The appellation
“dada ’’ is not limited to the child’s father until the twenty-first
month. But all these sounds are at first instinctive.
Perhaps the sound “ kak-kak’”’ or “‘ack-ack”’ is the most
striking example of instinctive language. It occurs in almost
every child belonging to the Aryan race, and is an expression of
disgust. The Hindoo word “ khaki’? means brown, the colour
of dirt, dust or feeces.* I have frequently heard the same sound
uttered by monkeys in the Zoo, when annoyed in any way by
another monkey. Now the monkey has no voluntary language;
this sound is therefore of instinctive origin.
It is doubtful whether the mother’s or nurse’s interpretation
* Cf. Ital. “cacare *’, to deftecate.
INSTINCT 69
’
of this sound as meaning ‘“‘ something nasty ”’ corresponds with
the original meaning in the mind of the child, who regards its
own feces—something created by itself—as important and even
valuable matter. Indeed, when unobserved by adult eyes,
children much older than this exhibit an interest in feces; and
many stories unfit for the drawing-room demonstrate that this
conscious interest does not always cease in riper years.
The infantile interest in and tendency to play with feces is
normally repressed into the unconscious. Notwithstanding, like
other instincts, it is never lost; psycho-analysis reveals that it
is sublimated in later life into all sorts of useful, social, moral
and conventional activities.
The sixteenth month is of great interest on account of the
very earliest beginning of voluntary language. The child will
say ‘ey’ (an attempted “ yes ’’) for assent; but the word “no ”’
is not used as a verbal negation until some months later.
Language is first learned by instinctive imitation. During
this month the child learns to say “ ta’’ when it is given any-
thing; but it does so instinctively, for volition has not yet
developed; myelinization of the pyramidal tract is only just
being completed. If the child is told to say “ta” or “ ta-ta”’
it does not respond, for the reason that to say a word to order
is a volitional act. A similar condition is frequently observed
in patients with motor aphasia, who will answer “no” to a
question, but cannot say “no ’’ when told to do so.
Imitation, which is by no means limited to language, is itself
aninstinct. Curiosity makes its appearance about the eighteenth
month, and it is a remarkable fact that this instinct is almost
always, if not invariably, initiated by some experience which—
in adult life—would be regarded as being of a sexual nature.
For example, a male child sees his mother’s breasts or a female
child has an opportunity of seeing her father naked. Parents
seldom realize how observant their babies are or how enormous
is the permanent influence on their plastic minds of even the
most trifling incidents; children are even permitted to observe
coitus far more commonly than is usually supposed. Never-
theless, the influence is not always harmful; for it is the sub-
limation of this instinct of curiosity which lays the foundation
of all investigation and research.
In the nineteenth month the child shows signs of acquisitive-
ness by clamouring for its brother’s or sister’s toys.
In the twentieth month he shows a desire for social inter-
course, the beginning of the gregarious or herd instinct.
70 MIND AND ITS DISORDERS
About the twenty-first month the instinct of cleanliness
appears, not active cleanliness, but the tendency to avoid filth;
and about the end of the second year, the child automatically
ceases to be “‘ wet and dirty’’. By education, this may be
achieved earlier. This is really one of the earliest “ repressions ”
(vide p. 179)—the repression of the interest in excreta.
The instinct of make-believe and play develops at the begin-
ning of the third year.
During the third year the child gets some idea “f time and has
a definite concept of past and future. Accordingly conscious
memory, on the one hand, and anticipation on the other, begin.
The instinct of rebellion also makes its appearance.
Destructiveness is an instinct which appears in the fifth year.
The child often exhibits this by pulling off the legs and wings of
flies; disinterested cruelty (sadism) is a primitive instinct. From
this year onward the boy loves to tease others and he fights others
with intent to do bodily harm. Here are the beginnings of the
instinct to kill, not only the lower animals for food, but even
human rivals.
Constructiveness develops a couple of years later. If a six-
year-old pulls his father’s watch to pieces, it is partly for the
purpose of giving himself the subsequent pleasure of putting it
together again.
Emulation and rivalry appear about this time. Children of
this age will, for example, vie with one another in collecting the
largest bouquet of wild-flowers for their mother.
The instinct to make collections of some kind usually shows
itself, at least in boys, about the ninth or tenth year.
The instinct to eat, which develops at a very early age, becomes
especially prominent about this time. At this age the boy eats
everything that is placed before him; there seems to be no
possibility of satisfying his appetite and he takes the greatest
interest in the “tuck-shop’’. I do not mean the sweet-
shop, but the “tuck-shop’”’ where they sell such things as
doughnuts.
The period between twelve and fifteen is characterized by
well-marked boastfulness and conceit. This usually develops
into a feeling of power, general bzen-étre and, if it is not soon
under volitional control, a state of simple mania.
The instincts of hunting, fishing and shooting, stronger in man
than in woman, for it is the man’s natural duty to provide food
for his family, develop shortly after puberty. In civilized
communities these last instincts usually find an outlet in open-
INSTINCT aI
air games. The study of general paralysis has led me to think
that the spending of money is also instinctive at first.
Parental love and jealousy are instincts which develop
later.
This by no means exhausts the list of instincts. There are
many others, the date of whose first appearance I have been
unable to fix, such as secretiveness, which causes people, even
in the wilds of the country, to pull down their blinds at sunset;
the instinct to comply with etiquette at table or in the ball-room,
and other social, moral and ethical instincts.
The reader has already said to himself: ‘‘ Love! Jealousy !
Modesty! These are emotions; these are not instincts.’”’ The
objection holds good to a certain extent. Instinct may be
regarded as the expression of an emotion (desire) which occurs in
-response to a group of sensations, be they the sensations which
a bird experiences when there is an egg in its cloaca, the visual
sensations of a cat when she sees a mouse or the visual sensa-
tions of a lover who sees his sweetheart walking with another
man. The resulting movements are the expression of the accom-
panying emotion. The only difference is that emotions are
usually more restrained than instincts; instinctive action goes
far enough to bring the organism into practical relationship
with the outside world. |
From disuse or constant inhibition many of the above instincts
may atrophy. Similarly, if the normal stimulus to an instinct
does not occur at the time when that instinct usually develops,
the probability is that it will never appear. For example,
a town-bred boy seldom acquires in after-life the instincts of
hunting, fishing and shooting.
Instinctive action on the occasion of its first occurrence is
blind; but after a given instinctive act has occurred several times
and its purpose has become clear, it can no longer be considered
blind. We must therefore regard instinct as being implanted
in us for the purpose of giving a series of cues to volition. The
first attempt at a purely instinctive act is good; indeed it may be
considered as perfect for all practical purposes although capable
of improvement; but the first attempt at a purely volitional act
is usually rather poor.
Some authors have described impulse as a separate form of
action. It is defined as action occurring without deliberation,
immediately upon the presentation of a percept or idea. On
examination of impulsive acts, however, it will be found that
they can always be referred to some instinct.
12 MIND AND iTS DISORDERS
Classification of the Instinets—Every animal is designed
primarily for the perpetuation of its species and secondarily
for the preservation of its own life, and the instincts above con-
sidered are nearly all subservient to one of these aims. Those
which are not are referable to sociability, gregariousness or the
herd instinct, to be examined presently; while a few may be
ascribed to two or more of the master instincts. For example,
modesty in dress may be assigned to the sex and herd instincts,
modesty in eating to the self-preservation and herd instincts.
Indeed, psychologists have deemed it wise to separate from the
self-preservation instinct a special instinct of self-nutrition; so
that we finally classify the instincts under four headings, viz.,
nutrition, self-preservation, sex and society. The word“ society ”
is here used as applicable to man; gregariousness of animals
generally, including man, is known as the “ herd instinct ”’.
Self-nutrition is indisputably the first instinct to show itself
in the new-born child. It is stimulated either by hunger or |
appetite; the former being an unpleasant sensation demanding
relief, while the latter is a pleasurable desire. It is at least
doubtful whether a baby sucks its mother’s breast because it is
hungry; it is more probable that its desire depends on the mere
pleasure of sucking, which is inhibited only by the sense of
surfeit.
Later, when the child has reached an age when it can choose
between one kind of food and another, the choice is determined
by taste and flavour memories. Children usually dislike fat but
like sweets, such likes and dislikes having been implanted in
accordance with the needs of the organism. Contrary to popular
notions, sugar 1s an important food for the young, while very
little fat is required to satisfy their physiological needs. The
great increase of appetite during the pubertal period, especially
in males, is worth noting.
The regular ordering of meals is a matter of custom, arising
from convenience, and varies in different countries, and the
instinct to go to a meal at a specified hour must be regarded as
more social than nutritional.
The instinct of self-preservation shows itself during the early
helpless years of life only by crying (for help) when the child
experiences pain or fear. As he grows older and ultimately
becomes an adult, he develops such instincts as courage, pug-
nacity, cruelty, revenge, deceit and dissimulation for purposes of
self-preservation or self-advancement, which is the same thing.
Contrary to popular belief, the foundations of the sexual
THE SEXUAL INSTINCT 73
instinct are laid in early infancy, just like those of other instincts.
This fact is at first rather distasteful to our more refined nature,
which likes to think of the child as “ pure’ and asexual; but it
is well known to many intelligent observers of children, not
excepting mothers, is acknowledged by the younger generation
of physicians who specialize in the diseases of children and is
demonstrated by the psycho-analytic investigation of hundreds
of adult patients.
The young child loves to manipulate its own body in a variety
of ways, such as thumb-sucking, nose-picking, nail-biting, rub-
bing the thighs together and rubbing its breasts and abdomen
with its hands when naked. Even masturbation is common,
and I have met with it as early as the ninth month. This is a
stage of “ autoerotism ”’
Of course the child has not the faintest idea of sexuality as
understood by the adult, but it is probable that during infancy
every sensory stimulus has some sexual significance. This
notion will be more easily comprehended when it is reflected
that, even in adult life, the sexual instinct may be aroused
through many of the sense-organs; for example, the eye (when
_ seeing a beautiful face or figure), the ear (when hearing a beautiful
voice or the rustle of a dress), the nose (when smelling certain
odours characteristic of the opposite sex) and the skin (when
feeling the skin of a member of the opposite sex, or even, in some
people, in experiencing certain painful stimuli).
It should be explained that the sexual emotion includes much
more than direct or reflex genital stimulation. Indeed, this
does not necessarily occur in most of the above situations.
Sexual emotion includes attraction, friendliness, ideal love and
many pleasurable thrills quite unconnected with and irrespective
of genital excitation.
As has just been said, a sensory stimulus to the infantile sexual
instinct may, during the earliest months, be given through any
part of the cutaneous surface; but, very shortly after, the element
of sexuality appears to be concentrated in four chief areas—the
mouth, the inner surface of the thighs, the anus and the neck of
the bladder. These are the four primary “ erogenous zones ”’ of
Freud. I think he might have added a fifth—viz., the breasts,
at any rate in females. Their erogenous character in females
persists into adult life.
To give detailed evidence respecting the erogenous zones would
unfortunately encumber a manual of this kind too much, and we
must be content with a mere hint as to the nature of the evidence.
a
74 MIND AND ITS DISORDERS
The mouth is first used for sucking the breast, and medical
psychologists discern something of the nature of an orgasm when
a satisfied baby flushes, leaves the breast and sinks into slumber.
Thumb-suckers tend to manipulate or rub their breasts during
their pleasure-sucking. The symbolism of kissing need scarcely
be mentioned; but it is not generally known that energetic
suckers in infancy are very fond of kissing in later life.
Pleasure obtained by rubbing the thighs together is frequently
observed in quite young infants, especially in girls.
Anal eroticism is chiefly noticed in young children who volun-
tarily retain their faeces in order to obtain what is for them
a pleasant sensation of violent muscular contractions necessi-
tating expulsion, in spite of the accompanying pain. This
desire is nearly always repressed in later infancy, but it may be a
factor in the constipation and certain other symptoms of some
neurotics in later life. Psycho-analysis reveals this instinct to
retain the feces to be the first attempt at economy, for such
persons invariably grow up thrifty and methodical, and it is
remarkable how frequently it is found during a psycho-analysis
that faeces symbolizes money. Incidentally it is also to be noted
that anal erotics have their own secret ceremonials in the w.c.
It is, of course, natural that the child should object to the grati-
fication of its desires being stigmatized by its nurse as a “‘ mess ”’;
but Nature appears to have provided for special excitation of
the anal area by periodical soiling and subsequent cleansing.
The neck of the bladder is demonstrated to be an erogenous
zone by the discovery that enuresis nocturna, except perhaps
when it is caused by idiopathic epilepsy, represents a pollution
corresponding to a sexual dream, even in cases of adherent
prepuce and the like. Similarly a full bladder in an adult is
liable to cause an erection during sleep.
During the first two years of life the human infant seeks
pleasurable gratification by stimulating various parts of its own
body (self-love or autoerotism), but this is repressed and for-
gotten during the dawn of the moral instinct in the third and
fourth year, with its constituent feelings of shame, loathing and
disgust, and later by the sublimation of the infantile sexuality
into useful cultural and social ends. Should adversity befall
this sublimating process, it lays the foundations of subsequent
neurosis.
During the fifth and sixth years the normal child seeks to love
somebody other than itself, usually the person with whom it
is brought most into contact—the mother, the nurse or their
THE SEXUAL INSTINCT iis
surrogates. It is to be observed, however, that the boy loves
his mother the more and the girl her father, unless the behaviour
of the parent of the opposite sex estranges the child. It seems
probable that the greater frequency of homosexuality among
women, whether acknowledged or repressed, may be due partly
to the fact that the father, being the wage-earner, plays a less
important part in the home circle.
The chief mental characteristic of puberty, with its numerous
physical manifestations, is the erection of incest barriers whereby
love for the parents becomes gradually weakened and the subject
during adolescence becomes attracted by persons of his or her
own age outside the family circle, but ultimately of the opposite
sex. More than this, the favourite parent usually serves as an
unconscious pattern for the future mate. Boys are attracted by
some girl resembling their mother and girls bya boy resembling
their father, at least in some mental or physical characteristic
which has appealed to them.
The normal development of the sexual instinct, as above
outlined, has been elucidated and confirmed by the psycho-
analytic investigation of hundreds, probably thousands, of cases;
but I fear that my endeavour to be brief and to pay due regard
to the sense of proportion may engender scepticism and leave
the student unconvinced. In many instances his own psychical
constitution or “‘ make-up ’”’ may be an unconscious cause of
his opposition to these truths. In such situations the critic’s
own self-analysis can alone convince him, perhaps with his
subsequent psycho-analysis of other people.
Those readers who are unfamiliar with modern psychology
will probably complain that too much attention has here been
paid to the sexual instinct. To such it must be explained that a
detailed study of this instinct is demanded, not so much by its
complexity as by the fact, which will appear later, that it plays
the most important rdle in the etiology of the neuroses and
psychoses.
Its importance, however, in common with that of the other
primitive instincts, pales before the last instinct-group we have
to discuss—viz., the ego-instincts.
We have to recognize that man is a gregarious animal—indeed,
the most gregarious animal there is, with his congregation into
towns and cities, his innumerable social institutions and organi-
zations, cliques, sets, classes, sects, unions, societies, associations,
committees, clubs, municipalities, armies, parliaments, nations,
empires and what not. Man, being more dependent upon com-
76 MIND AND ITS DISORDERS
munal life than any other animal, is miserable by himself, and
his faculty of speech, peculiar to him alone among ali animals,
becomes useless when he is alone. Asa matter of fact, language
is nothing more than the final outcome of super-gregariousness.
The advantage of gregariousness is that it ensures homogeneity
of the herd and impels its constituent units to act in concert.
This is of the utmost importance in hunting and warfare for
example, for it is clear that the prey or enemy would be more
easily vanquished by a large number than by a single unit.
Homogeneity of a herd is secured by an inherent impulse in each
individual unit to act in the same manner as his fellows. This
herd instinct, like other instincts, is maintained by natural
selection; for departure from the customs of the herd deprives
the individual of the advantages of gregariousness, even if he
escapes immediate death for his pains.
Every herd has habits and customs of its own, but the par-
ticular herd which concerns us now is that of civilized man, and
it behoves us to inquire what features of human conduct are
determined by the desire to conform with the habits of his fellows.
For our present purpose the habits of even the savage races of
mankind are of no moment.
Clearly self-preservation and the gratification of nutritional
and sexual desires are not primarily undertaken with the intent
of pleasing one’s fellows, although it must be admitted that the
herd instinct is occasionally brought into play for purposes of
self-preservation, especially in time of war; that dining in com-
pany is a recognized custom, because it is more agreeable than
a solitary meal; and even that sexual orgies are occasionally
arranged among the dissolute. The herd instinct in man is so
strong that it pervades even his personal instincts.
But what are the present-day customs of civilized man which
are referable to his herd instinct ? In seeking an answer our
thoughts naturally turn to such topics as Art, Science and
Literature. Literature has its basis, of course, in language, the
prerogative of man; but it is questionable whether man can
arrogate all Science and Art to himself in view of the activities
of the bower-bird, certain song-birds, the trap-door and other
spiders and the beaver—all, be it observed, non-gregarious
animals. Moreover, the artistic productions, scientific dis-
coveries and literary efforts of man are individual endeavours to
obtain a livelihood or, at best, an outlet for personal energy or
horme. Intrinsically there is not the slightest gregarious element
about them. Science, the impartial search for truth, would
THE HERD INSTINCT fi
indeed be vitiated by any attempt to please the community; for
it is a matter of common experience among scientific investi-
gators that any new discovery which tends to correct traditional
belief, however erroneous, instantly receives antagonistic criti-
cism and frequently scurrilous abuse. Literature and Art also
have to abide by certain conventions of the human herd.
The essential bases of human conventions are tabulated in the
ten commandments of Moses, and we are given a more modern
idealistic interpretation of these in Christ’s Sermon on the Mount.
Although very few of us act strictly up to the principles of sym-
pathy and self-effacement therein enunciated, we would all be
prepared to accept them as ideal rules of conduct and to de-
nounce antipathy and self-assertion as antisocial. Freud has
called them the “ ego-ideals ’’ and speaks of the desire to act
up to them as the “ ego-instinct ”’
On the other hand, we are faced by the patent facts that people
sometimes give offence to one another of set purpose, rejoice in
gossip, scandal, guile, deceit, trickery and fraud, and even in-
dulge by thought, word or secret deed in many varieties of sexual
debauch. All such thoughts and actions clearly originate from
_ the primitive animal personal instincts of the subject and are
inharmonious with his ego-instinct, which is never dead, even
in the basest criminal; they therefore tend ultimately to cause
intrapsychic conflict. Should the subject fail to admit to him-
self that he is immoral, as frequently happens, he may even
forget that his offence was ever committed: in psychological
language, it is repressed into the unconscious.
In view of many of the above eonsiderations it need scarcely
be urged. that desire to comply with the wishes and customs
of human society is a true instinct inborn in each individual,
although its manifestations do not appear for some years.
Modern psychological investigation confirms this fact; for it is
quite frequently elicited that a patient has, for example, ex-
perienced a sense of shame or modesty as early as two years of
age on being observed naked by a stranger. But why? What
harm is there in being seen naked? There is no conscious
reason for it, and some primitive yet perfectly moral races of
nrankind go about naked without detriment. We can only say
that it is an instinct, the significance of which is shown and its
origin symbolically given in the story of “the Fall” in the
Garden of Eden, after which our first parents are said to have
““made themselves aprons’’. The inner hidden meaning of this
narrative will not escape the student of psychology.
78 MIND AND ITS DISORDERS
Our conclusion is, then, that the chief characteristic of civilized
man is that he is moral, which means that he tends to repress
his personal instincts in order to comply with the wishes and
ordained customs of his fellows. This applies especially to his
sexual instinct, for common talk identifies “‘ morality ’’ with
repression of sexual desire rather than abstention from thoughts
or acts of murder, theft or falsehood.
We must, therefore, in spite of all sentiment, face the fact
that the chief characteristic of human psychology is that man,
as a herd, is opposed to all ideas and thoughts respecting sex.
So strong is this peculiarity that even many doctors, who pre-
sumably regard themselves as scientific men, consider the strictly
scientific study of sexual matters to be improper. Gynecologists
suffered for many years, specialists in venereal disease are still
rather derided, but psycho-analysts are roundly reviled as
immoral.
VOLITION.
Voluntary action is that which occurs after deliberation, the
individual making a choice between one action and another or
between action and inaction. As long as indecision lasts there
is a conflict of motives, which we call deliberation ; and as long
as deliberation lasts inaction is the result.
The final decision to act is reached in one of two ways. In the
first, all the conflicting motives have been considered, a con-
clusion formed as to what is the best thing to do and we do it.
In the second, deliberation is cut short and decision is forced
upon us before we have considered all the evidence. ‘“‘ The
house is on fire! For God’s sake, do something! It matters
not whether you fetch a bucket of water or run to the fire-station
or get the people out of the house; but act at once without
further deliberation.’’ Again: “ Which boot shall be put on
first ? It matters not; deliberate no longer, but act at once or
the day will be gone.”’ The latter form of action is probably
the more common of the two.
This appears at first sight to be all very simple; but we have
to realize, on the one hand, that it must be exceedingly seldom
that all the conflicting motives to action or inaction come to
mind (enter consciousness) and, on the other, that the selection
of even precipitate action must have some sort of driving force
behind it. Such considerations force us to the conclusion that
unconscious factors must be at work.
VOLUNTARY ACTION 79
Every action we perform is determined by the existing cir-
cumstances and environment of the moment lus an enormous
number of previous experiences, either remembered or forgotten,
which bear upon the situation. Moreover, even the most
voluntary act is much more determined by unconscious trends
and motives than by conscious deliberation. In fact, every
action—even the most voluntary—is the only one which could
possibly be executed by a given individual under such circum-
stances at that moment. This is the scientific doctrine of
“psychical determinism ’”’, which is totally opposed to the
popular notion of ‘‘ free will’. There is abundant evidence
among modern psychological investigations to justify this doc-
trine, but it would lead us too far afield to discuss the matter
further at present, and the student must defer his judgment until
he has acquired some familiarity with unconscious mechanisms.
Movement itself unless inhibited is the inevitable sequel to
the idea of movement; this is shown by introspection. If the
reader will form a vivid idea of some movement (for example,
getting up to open the door) he will find that the muscles neces-
sary to the movement at once begin to contract; and he will
_ actually cross the room unless the action is inhibited by the
thought that he is only performing an experiment.
Among the enthusiastic crowds which attend football matches,
it is quite a frequent occurrence for some member of the crowd
to receive a violent kick from an onlooker behind him when one
of the players is kicking the ball. Such an onlooker forms a
vivid idea of kicking the ball himself and the idea sets free the
movement.
We see then that volitional action originates in ideation, and
we must infer that its physical basis is in the ideational centres,
that is to say, in the cortex cerebri. From the study of pre-
frontal tumours, it has been found that the ideomotor centres,
where movement-ideas arise, are situated in the left prefrontal
lobe. The left prefrontal lobe must therefore be regarded as
the physical basis of volition. In the above instance the idea
of kicking is formed firstly in the visual perceptual areas, near
the occipital lobes, and secondly in the motor ideational area of
the left prefrontal lobe.
The diagram of the cerebral centres of movement on p. 32 is
adapted from Griinbaum and Sherrington’s work on the brain
of the chimpanzee and from other diagrams.
The dawn of volition, including voluntary language, occurs
about the age of seventeen months. Volition continues to
80 MIND AND ITS DISORDERS
develop at least up to thirty years 6f age and perhaps much
later.
I have said that the function of instinct is to give the cue to
volition. In other words, the pyramidal system tends to take
over some of the work of the cortico-rubral system. In this
way volition acquires control of instinct; and the essential
feature of a man with a strong and stable personality and a fine
character is that he has complete control of his instincts.
Inaction arises from one of five causes: (a) A generally in-
attentive condition of consciousness (day-dreaming); (b) absence
from the ideas in consciousness of anything to suggest the idea
of movement; (c) equal strength of the motives for several actions,
deliberation being still in progress; (d) inhibition of action by
some strong emotion, such as fear; and (e) the conclusion that
inaction is more advantageous than action.
AUTOMATIC ACTION.
Automatic action is action which at one time in the history
of the individual has been volitional but, owing to the frequency
with which the particular act has been performed, is now carried
out without psychical concomitants and is relegated to the
subconscious. Walking, winding one’s watch, turning out the
light when one goes to bed, and turning over the pages of a book
are typical automatic actions.
The favourite example is a practised pianist who can play a
piece of music while he holds a conversation on some topic quite
unconnected with the music and meanwhile pays no heed to
the movements of his fingers. Such phenomena as these illus-
trate the ease with which the nervous system forms a “ habit ”’.
It has been said that “‘ Habit makes easy’. Not only is this
the case, but it is also true that it is extremely difficult to free
oneself from a habit, at least after thirty years of age.
There are two differences between a voluntary and an auto-
matic act. One is that a voluntary act necessitates attention
to its performance while an automatic one scarcely arouses
phenomenal consciousness. The other is that a movement-idea
precedes a voluntary act, but not an automatic act.
Now in advanced cases of senile dementia, voluntary and
automatic actions are in abeyance, although there is no true
paralysis indicative of damage to or atrophy of the Rolandic
areas of the cortex. In such cases there is atrophy of both
frontal lobes, but no affection of the precentral gyri. It seems
HABIT Sr
therefore reasonable to conclude that the physical basis of both
volitional and automatic action is situated in the prefrontal lobes.
Why is it that attention is not aroused by the performance of
an automatic act; except, sometimes subsequently, when one
finds that one has acted inappropriately, e.g., wound up one’s
watch when changing into evening dress ?
In the study of automatic action we are brought face to face
with the fact that some cortical cerebration takes place without
awakening consciousness; it is unconscious. Now it is well
known that synaptic resistance is permanently lowered whenever
that resistance is overcome, and therefore that frequent over-
coming of that resistance must finally reduce it almost to ml,
thus creating a tendency for the particular interneuronal con-
nections to occur again. But how are we to explain the fact
that the consciousness of frequently repeated actions gradually
sinks into the background ?
There need be no difficulty in answering this question. The
phenomenon is self-explanatory; it demonstrates the fact that
consciousness is mainly aroused by the formation of unusual
interneuronal associations.
No misconception need arise from this popular but some-
what erroneous use of the word “consciousness’’. When a
person says, “I did it unconsciously ’’, he does not mean that
he was unconscious at the time that he did it; he means that
he did it without paying any attention to the action. The
conclusion, therefore, at which we have arrived is that “ atten-
tion’’ is aroused by the formation of unusual interneuronal
associations, by the overcoming of synaptic resistance where
that resistance is still high, while some cortical cerebration may
occur independently of any activity of the “attention ’’. When
we say that the attention is aroused by the formation of unusual
interneuronal associations, we are only stating in another form
a truth which will be repeated in the chapter on Attention, viz.,
that the suddenness’ of a stimulus is a character which causes
it to engage our attention, and suddenness is nothing more or less
than “‘ non-associatedness’’. Inasmuch as attention plays an
important part in determining the remembrance of any particular
idea, automatic acts are remembered with difficulty.
THE REACTION EXPERIMENT.
Action has been reduced to its laboratory form in the so-called
reaction experiments. The essential piece of apparatus for the
estimation of reaction-time is a “ chronoscope”’ of some kind.
6
82 MIND AND ITS DISORDERS
This is an arrangement by which time can be measured to a
thousandth of a second and is so adjusted in connection with
other apparatus that the time may be measured between the
giving of a stimulus to sensation and the motor reaction of a
subject in response to the stimulus, which reaction consists of
his pressing a button (electric or otherwise) also in connection
with the chronoscope. An ordinary physiological drum with
a tuning-fork might serve the purpose, but the noise of the
tuning-fork is rather distracting to the subject. 3
The apparatus is used in many ways. In the natural reaction
a stimulus is given to vision, touch, hearing, smell or taste,
and the subject presses the button as soon as he experiences
the sensation. The sensorial reaction is similar, but in this
case the subject is required to pay special attention to the
character of the stimulus and resulting sensation. In the
muscular reaction special attention is given to the move-
ment. The experiment may be modified in many ways;
for example, the subject may or may not be warned by
the experimenter that he is going to give a stimulus; a
couple of seconds before the stimulus is given the experimenter
may say “Ready’’ or ““Now’’. These modifications of the
attention make considerable difference in the reaction-times.
Here are some figures:
Touch. Vision. Hearing.
Second. Second. Second.
Natural ee =i ie. . O'12—O°18 O*19—0°22 O*I4—0°19
», (without warning) ie es 0°25 — ——
Sensorial .. “- Bh oe O-21 0°27 0°23
Muscular .. - ip v2 ay? Or1l 0-18 OrI2
The variation in these results has more bearing upon the
phenomena of attention than upon those of action. All that we
learn from them is that a movement is released more rapidly if
attention be directed to it. Variations in the natural reaction-
time depend upon differences in the ideational type of different
individuals; some types are more motor, visual or auditory
than others.
The reaction experiment can be varied ad infinitum. For
example, it may be used to demonstrate that it takes longer to
react with the foot than with the hand, longer still to react with
the whole body as in making the start fora race, and it has been
found that the reaction-time of long-distance runners is longer
than that of sprinters.
Now all these data may be very interesting, but they teach us
THE REACTION EXPERIMENT 83
~
little about the psychology of action if the reaction experiment
is regarded as an end in itself. If, however, it be used as a means
of introspecting action in its laboratory form, it is found to
confirm the conclusions at which we have already arrived by
cruder methods of investigation. When a reaction experiment
is performed the subject should give the results of an intro-
spection during the proceeding. If he be a practised observer
his introspection will be something like this:
Muscular Reaction.—‘ I had a strain sensation extending from
the elbow to the finger. I had a vivid idea of the movement
which I was about to perform and to which my attention was
directed. I scarcely noticed the stimulus, but felt that it was
a relief to move.”
Sensorial Reaction.—‘* My attention was wholly directed to
the stimulus; (perhaps) I was afraid that I should react to a
false stimulus; I then had a visual idea of my own movement
and of the apparatus.”’
The former is, perhaps, impulsive action in laboratory form;
the latter is “‘ action after deliberation’’ in its simplest form.
This is, however, more characteristically represented in the
laboratory by the “ discrimination reaction’’. In this experi-
ment the subject is required to react to one stimulus only,
although several may be given; for example, he may be required
to react to the colour blue only although he may receive the
stimuli of other colours. As a matter of fact, the experiment
scarcely differs from the ordinary sensorial reaction experiment,
because it is customary in the latter to give an occasional false
stimulus.
In the “ choice ’’ reaction experiment, the subject has to react
differently to different stimuli; e.g., he has to react with his
right hand to blue and with his left to red (simple choice). Or
he may have to react to ten different stimuli with each of
his ten fingers respectively (compound choice). Choice-time is
obtained by subtracting discrimination-time from the times
obtained in these “ choice ”’ experiments.
Cognition-time is obtained by subtracting discrimination-time
from the time taken to cognize a given object, association-time
by subtracting discrimination-time from the time required for
the development of an associated idea. The association-
reaction is of course made with the mouth in naming the
association; a special mouth-key is accordingly provided for
this experiment.
The reaction-times obtained are of little value without corre-
84 MIND AND ITS DISORDERS
sponding introspections; but a few are here appended to give
an idea of the duration of these mental processes:
Second.
Cognition (colour) du8 oe Me aol POs
- (short word) .. a ae .. SO°e5
Choice (two movements) Ss oe i oe
,, (ten movements) on ge 1's PROEe
Association-time .. Ma a ie .. 0°3-0°8
The more practice a person has in reactions of this nature, the
more automatic and habitual the reactions are to him, the
shorter are his reaction-times. In other words, reaction-time
is shorter for automatic than for volitional action. The above
times are those of practised observers.
Unconscious ACTION.
The manner in which automatic action, as above understood,
becomes relegated to the subconscious requires no further de-
scription, but reference must here be made to the phenomenon
known as “ automatic writing ’’: ‘‘ unconscious writing ’’ would
be a better term.
Certain people, usually of a neurotic temperament, are capable
of acquiring the faculty of allowing the hand to write matter
of which they are entirely unaware, their attention being engaged
for the time being in some other way, such as conversation or
reading a book. At first it is usual for such writing to be a
nonsensical scrawl, but, with time and practice, it develops into
a record of previous experiences or elaborate fictions or a com-
position in verse, even in a foreign language. The subject is
for the moment split into two personalities with two separate
and independent activities, a phenomenon which will claim
further consideration in subsequent chapters.
Other unconscious actions are the somnambulism of deep
sleep and the hypnotic state, and the performance during the
normal state of certain acts which have been suggested to the
subject while under hypnosis.
Lastly, there is the state known as absent-mindedness. It
happens to every one of us at times that we place articles in
unusual spots, find subsequently that they are lost and, when
they are discovered, have no recollection of having misplaced
them. In this way, even valuable documents are sometimes
thrown away or destroyed and their disappearance remains un-
explained. Yet, by artificial means of tapping the subconscious
(crystal-gazing, hypnotism etc.), these absent-minded actions
UNCONSCIOUS ACTIONS 85
can often be brought back to memory and phenomenal con-
sciousness. When an object is mislaid, there is almost invariably
subsequent amnesia of the act; indeed, this is the main feature.
Both the action and the memory of it are repressed, a combina-
tion of psychical activities which suggests that there must be
some unconscious motive for the mislaying of objects. This
supposition is confirmed by closer investigation, which reveals
that the underlying motive is either an unadmitted wish not to
see or use the article or a secret wish to keep it out of mind lest
it should remind us of some unpleasing incident. Bills are mis-
laid more often than cheques, and even valuable presents from
people we dislike are liable to be lost.
So with slips of the tongue and pen, and misprints. These are
usually due to a desire to hurry through a sentence or topic, but
frequently they betray an unconscious wish of the speaker or
writer. Punch almost weekly records misprints of interest, and
his witty comments are often quite sound from a psychological
point of view. The current number at the moment of writing
(third edition) contained this gem from a provincial paper:
“The bride carried a sheaf of harem lilies and orchids’, which
_Taises the question whether the printer had any knowledge of
Greek.
Erroneously carried-out actions come into the same category.
The giving of wrong change is a familiar example, the error
being usually in favour of the person who makes it. The sup-
posedly accidental breakages by domestic servants supply
another example. The servant would never admit, even to
herself, that the breakage was intentional; but it gratifies some
unconscious wish, such as reduction of labour, tending to equalize
the property of herself and her employer, personal revenge or
some such kindred unconscious desire.
Similarly, many apparent accidents of everyday life are
determined by unconscious motives; for example, taking the
wrong train, missing the train, unusual arrangement of ornaments
or articles of furniture without conscious reason, habitually
applying the wrong key to a lock, and so forth. All such mental
phenomena prove, on analysis, to be very strong arguments in
bi
favour of the doctrine of “‘ psychical determinism ”’.
Ce Walang etd ve AOL.
ATTENTION.
WE are now in a position to understand the nature of attention.
Altention 1s that process by which the organism is placed in the
attitude best adapted for the reception of stimuli arising from an
object attended to or noticed ; whereby the perception of such object
becomes clearer and more distinct in consciousness.
The accuracy of this definition will be established as we pro-
ceed. The attitude of the organism during attention to an
idea of an object resembles that during attention to a percept of
the object.
THE LAWS OF ATTENTION.
1. The truth of the assertion that attention to a percept or
idea renders such percept or idea clearer and more distinct is
well illustrated by the “ puzzle pictures ’’ of cheap periodicals.
There is perhaps a representation of a landscape and a hunts-
man and we are told to “‘ Find his dog’’. As soon as we find the
dog it is so clear and distinct that we cannot look at the picture
without seeing the dog and it becomes a matter of surprise that
we did not see it before. At the same time, while we are looking
at (directing our visual attention to) the dog, we observe that
the rest of the picture falls into the background, is less distinct
and less clear. This feature is also noticeable in listening to an
orchestra. If we single out any particular instrument and
listen to it, z.e., attend to it, it becomes clearer and more distinct,
while the rest of the orchestra becomes less clear and less distinct.
Moreover it is to be noted that there are only these two degrees
of clearness and distinctness of sensations and percepts, clear
and not clear, distinct and not distinct; there is no gradation.
It is true that there are degrees of attention: an object may be
attended to in such a degree that nothing else is noticed for the
time being (absorbed attention), as in the historical instance of
Newton neglecting to dine when working out his system of
fluxions, or it may be attended to only a little more than other
processes in consciousness; but in each case there are but two
degrees of clearness and distinctness.
86
LAWS OF ATTENTION 87
2. Under certain circumstances, it is also to be observed that
a sensation becomes more intense during attention. This is only
true, however, when the sensation is of slight intensity. The
pressure of our clothing passes unnoticed as a rule; but when any
particular part of the skin is made the object of attention, the
sensation of pressure there may become so intense as to necessi-
tate readjustment of the clothing over it. Ifa chord be struck
- on the piano and allowed to ring off while one of its constituent
tones is singled out by attention, that tone at once becomes
louder, more intense.
3. It has been demonstrated in the laboratory that a sensa-
tion of extremely brief duration becomes longer when attention
is directed to it.
4. A sensation or percept enters consciousness more quickly
when attention is directed to it. A hammerman sees the sparks
fly before he sees his hammer strike the iron. If a bell-metro-
nome be set in motion and attention be directed to the tick, the
tick is heard before the bell; but if attention be directed to the
bell, the bell is heard before the tick.
5. The above experiment also serves to illustrate the pheno-
_menon known as the inertia of attention. If, by an act of atten-
tion, the tick be heard before the bell, it continues persistently
for some considerable time to be heard before the bell, in spite
of efforts being made to hear the bell before the tick.
6. Another characteristic of attention is that it fluctuates;
and it can easily be demonstrated that this fluctuation has a
regular periodicity. If a watch be placed in the corner of an
otherwise silent room and listened to from the oppostie corner,
it is found that the ticking is alternately heard and not heard
about every four seconds. The same phenomenon may be
demonstrated in the domain of vision by means of a Masson’s
disc. A black spot is painted near the periphery of a white disc;
when this disc is quickly rotated on a colour-top, the black spot
appears as a very faint grey ring ona white ground. If this grey
ring be fixated continuously it is found to be alternately seen and
not seen about every four seconds. Minimal pressure stimuli
behave in the same way. Lehmann has shown that this pulse
of attention appears to be dependent upon the respiration.
7, Experiments have been made with the object of deter-
mining the number of things to which we can attend at the same
time. In most of these experiments a number of letters or
figures are exposed to the gaze for a very short time, say one-
tenth of a second, and the observer is then required to name
88 MIND AND ITS DISORDERS
the letters that he saw. Asa rule the number does not exceed
five or six. That this does not depend on any normal deficiency
in the visual apparatus is shown by the fact that at least twice
this number of letters can enter consciousness if they be arranged
into words. Under such circumstances several letters combine
to form one idea.
THE VARIETIES OF ATTENTION.
Voluntary Attention.
By introspection we find that there are many sensations and
percepts to which we are unable to attend without a certain
amount of voluntary effort. Attention to sensations of minimal
intensity, to a lecturer with a bad delivery or to a book on a
difficult and unfamiliar subject, is accompanied by a distinct
sense of voluntary effort.
Now if we endeavour by introspection to discover the con-
stitution of this sense of effort we find that it is made up of
numerous sensations of muscular strain. The muscles of the
eyes and upper part of the face come into play in attention to
visual percepts or ideas; the head is turned in attention to
auditory percepts or ideas; there is movement about the lips
in attention to gustatory sensations; and accompanying these
movements there is in voluntary attention a sensation of muscular
strain. If we endeavour by introspection to discover anything
more than these sensations in the feeling of effort, we fail. The
conclusion is therefore that this sense of effort (sometimes
called “‘ conation ’’) consists of nothing more than a number of
sensations of muscular strain. Further examination of this
muscular contraction reveals that its purpose is to place the
organism in the attitude best adapted for the reception of stimuli
from the object attended to.
Since these muscular contractions are volitional, we may con-
clude that they originate in the frontal lobes and that the motor
impulses are conveyed by way of the pyramidal tract. Mosso
demonstrated that during an act of attention the respiration
becomes slower, deeper and more diaphragmatic.
Instinctive Attention.
In contradistinction to sensations and percepts attention to
which is impossible without effort, there are others which im-
mediately claim our attention. Attention is thus involuntarily
(instinctively) brought into play by (1) stimuli of great intensity
INSTINCTIVE ATTENTION 89
and by (2) stimuli affecting a large area of skin or retina.
(3) Suddenness of stimulus claims involuntary attention, possibly
on account of the nervous system having been at rest from
previous excitation. In this case the stimulus overcomes a
large amount of synaptic resistance. (4) Movement of an
object arouses the attention probably for a similar reason,
fatigue of the sensory tracts being reduced to a minimum.
(5) Association and (6) contrast of the stimulus with the exist-
ing contents of consciousness also favour the development of
involuntary attention.
Lastly there is the question of ‘‘ interest ’’. Interest in a given
object depends upon the mental constitution of the individual.
This in turn depends upon hereditary and acquired mental
characteristics. Acquired mental characteristics are the result
of education, not merely the education received at home, at
school and at college, but also that derived from the individual’s
conversation with his associates and from his own observation
of his environment. Hence one individual will have an interest
in postage-stamps, another in butterflies, a third in the govern-
ment of his country, a fourth in geology and so forth. Any
of these individuals will, in one minute’s glance at his morning's
paper, discover whether there is any information concerning his
particular hobby. The word “ butterfly ’’ at once catches the
eye of number two, while the word “ trias’’ attracts number
four.
Hereditary mental characteristics are developed as a natural
result of the struggle for existence in past ages, and these inborn
tendencies determine what must of necessity be of interest
to the organism and engage its attention. A sound may be
the roar of a beast of prey, an object moving across the field
of vision is a possible meal; and the individual who takes no
interest in and gives no heed to such stimuli as these pays for
his inattention with his life. Thus we find that attention, like
affection, is the inevitable result of the normal processes of
evolution.
In each of the above instances, a moment’s consideration
reveals that the act of attention to a particular percept con-
sists of a movement, placing the organism in an easy attitude
for the reception of sensations constituting the percept.
From the above discussion we may conclude that attention
of this nature is instinctive in origin and that it must therefore
be referred to the cortico-rubral system of neurons.
90 MIND AND ITS DISORDERS
Reflex Attention.
It has just been said that suddenness of a stimulus causes
that stimulus to claim involuntary attention. It is, however,
almost certain that attention thus aroused is in most instances
reflex in character and therefore referable to the lowest level of
the nervous system. When, as I am engaged in writing these
pages, the whistle in my room is suddenly blown, I experience a
“start ’’, consisting of a momentary contraction of the muscles
of my back, shoulders and neck. The muscular sensations
arising from this start and the sound of the whistle arouse con-
sciousness at the same time; I do not first hear the whistle and
then start; the muscular contraction is therefore a reflex action
referable to my lower motor neurons. Probably many of the
conditions of instinctive attention mentioned at the top of the
previous page really belong here.
We have to recognize that there is a certain amount of inter-
change between these three varieties of attention. In imme-
diate succession to the reflex “start ’”’ there is a certain amount
of instinctive attention to the whistle; then follows an act of
voluntary attention consisting of rising and listening to the
message transmitted up the speaking-tube. In listening to a
lecturer with a bad delivery the sense of voluntary effort dis-
appears from time to time when the subject becomes interesting ;
and indeed we find during any lecture that attention becomes ~
alternately voluntary and instinctive, and passes through stages
in which the two varieties are blended.
It seems fairly clear that there is also an automatie form of
attention, for experience teaches us that constant efforts of
voluntary attention create a “habit of attention’ and render
the action easier of performance.
In considering the reaction experiment, we found that atten-
tion to the movement shortened the reaction-time. As was
stated on p. 8, this is a simple example of facilitation. It
illustrates the utility of muscular contraction as the essential
feature of attention; it is the placing of the motor mechanism
in readiness to act in response to a stimulus.
Unconscious Attention.
Attention undoubtedly occurs in dreams, sometimes to such
an extent as to leave the dreamer tired. It also occurs in the
somnambulism of sleep and hypnotic states, and it is obvious
UNCONSCIOUS ATTENTION OI
that unconscious attention must play some role in the pheno-
menon of “ automatic writing ’’.
“Interest ’’ is, of course, a conscious variety of attention; but,
from what has been said about it, the reader will have correctly
inferred that it is stimulated by unconscious motives. Indeed,
it is probable that our ultimate conclusion will be that “ interest ”’
is identical with “ instinctive attention ”’
To sum up: Attention is a motor reaction placing the organism
in an attitude whereby a percept attended to rises rapidly, clearly
and intensively into consciousness, and the organism is placed
in a state of alertness which may be of vital importance to the
individual. It is, in fact, nothing more than a special variety
of action.
CHAPTER VIII.
FATIGUE, SLEEP AND DREAMS.
AFTER action, fatigue! Fatigue may be defined as a diminution
of muscular or intellectual power, arising from prolonged activity
of any kind and accompanied by a sense of weariness. Fatigue
occurs more readily in old age than in youth, in sickness than in
health, in women than in men, and in some people than in others
of the same age and sex. Also, we are more fatigued by unusual
work than by work to which we are accustomed and more readily
in poor than in robust health.
Different people become fatigued in different ways. With
some there is at first an increased capacity for work, this being
followed by gradually diminishing capacity; with others there is
no initial increase, but the capacity for work diminishes from
the first; with a third class the capacity for work remains at a
high level for some considerable time, then fatigue sets in almost
suddenly; in yet another class the capacity for work diminishes
rapidly at first, remains at a moderate level for some consider-
able time and finally is reduced to mil. These features can be
reproduced graphically in ergographic tracings made by these
several people and presently to be described.
Muscular fatigue is characterized by a certain amount of pain
in the tired muscles; fatigue in general is characterized by
quickened pulse and respiration, dilatation of the cutaneous
arterioles, with perspiration and a consequent fall in the body
temperature. With some people, perhaps with all, this fall of
body temperature is preceded by a rise. Yawning is a fairly
constant feature, as is also a sense of hghtness, heaviness or
weariness of the legs. The power of attention is diminished,
ideas tend to become confused and there is weakness of memory.
There is loss of control of the musculature for fine movements,
a feature which shows itself in the handwriting.
Some people when they are tired are subject to palpitation,
indigestion, dizziness, vertigo, irritability, a sense of heaviness
or of lightness in the head, tingling and other sensations in
various parts of the body and hallucinations of vision or even of
Q2
MUSCULAR FATIGUE 93
hearing. These latter symptoms are to be regarded as charac-
teristic of exhaustion rather than fatigue and should be taken
as a warning note that the person requires a holiday.
Muscular Fatigue.—If a muscle-nerve preparation be made
with the gastrocnemius of a frog and a graphic record be taken
of some 250 contractions induced, at intervals of a second and a
half, by electrical stimulation of the nerve, we are enabled to
study the effects of fatigue on the muscle. We find that con-
traction and relaxation of the muscle become progressively
slower, that there is a progressive increase of power during the
first ten or twelve contractions and that afterwards the muscle
becomes progressively weaker until at last it cannot be induced
to contract at all. According to Kronecker, the curve of decline
in the contractions is a straight line (law of fatigue).
Left to itself, such an exhausted muscle will recover in the
course of an hour or so, but if the nozzle of a syringe be inserted
into the artery of the muscle and the muscle be washed through
with normal saline solution it will recover immediately. More-
over, if the washings be injected into a fresh muscle they will
immediately induce fatigue of that muscle. We learn from this
_ experiment that the phenomena of fatigue are due to products
which act as a sort of poison to the muscle. Further, if the
blood of a dog fatigued by excessive exercise be transfused into
the vascular system of a fresh dog, the latter at once shows signs
of fatigue.
The composition of the products of fatigue, so far as I am
aware, has not yet been completely determined. All that we
know is that the chief substances formed when a muscle con-
tracts are lactic acid and carbon dioxide and Mosso has suggested
that some leucomaines (alkaloids formed by living tissue) may
also be produced. At present, however, there is no conclusive
evidence that any of these substances is wholly responsible for
the phenomena of fatigue; but we are all familiar with the fact
that a stuffy atmosphere (carbon dioxide and moisture) is inimical
to successful work and often induces sleep. |
In man fatigue has been studied mostly by the aid of an
instrument called the “ ergograph ’’, devised in its original form
by Professor Mosso of Turin. It consists of two parts: (1) an
arm-rest with a pair of bits to hold the hand in position and
(2) a pulley connected with an apparatus for registering move-
ments made by one of the fingers to which is attached a string
supporting, over the pulley, a weight of about 3 pounds. The
ergograph is a contrivance for recording the curve of fatigue of
Q4 MIND AND ITS DISORDERS
different individuals under varying circumstances; this is called
an “‘ ergographic tracing ’’.
In making a tracing the finger is flexed as much as possible
every two seconds, this procedure being continued until the
flexor muscle is completely fatigued and the finger quite use-
less. The contractions may be executed either voluntarily by
the person under observation, or involuntarily by electrical
stimulation of the motor nerve of the flexor muscle of his finger.
When the involuntary method is used, the curve obeys the law
of fatigue; it declines in a straight line. With the voluntary
method the curve varies with different individuals according to
the way in which they severally become fatigued (vide supra).
Maggiora has shown in the following way that the later con-
tractions are much more exhausting than the earlier, although
they do much less work. As a rule, two hours’ rest is sufficient
for all trace of fatigue to disappear from a muscle completely
exhausted by, say, thirty contractions against the ergograph.
Now if only fifteen contractions are executed, the muscle is
completely rested in half an hour; the requisite amount of rest
is reduced to a quarter when the number of contractions, although
doing the greater portion of the work, is reduced by one-half.
Hence Maggiora deduces the “ law of exhaustion ’’, which is that
‘““ work done by a muscle already fatigued acts on that muscle in
a more harmful manner than a heavier task performed under
normal conditions ”’.
Contracture.—We have seen that, in the case of an involuntary
ergographic tracing, there is a general increase of the amount of
work done by the first few contractions. By some this is ascribed
to the effect of practice, by others it is considered to be the very
earliest sign of fatigue. In favour of the latter view is the fact
that, in some excitable and nervous people who are easily sus-
ceptible to fatigue, the muscle under investigation does not
completely relax between the contractions, with the result that
the summit of the curve remains high until fatigue is almost
complete; and it is a matter of common observation that, when
a hypermetropic eye becomes fatigued, the patient suffers, not
from inability to accommodate, but from difficulty in relaxing
accommodation; in other words, from spasm of the ciliary
muscle. In the study of intellectual fatigue we shall meet with
analogous phenomena.
Intellectual Fatigue.—If an ergographic tracing be taken after
prolonged mental exertion, it is found that the capacity for
muscular work is either increased (Rivers) or greatly diminished
INTELLECTUAL FATIGUE 95
(Mosso). On closer investigation it is found that tracings taken
during the earlier stages of mental fatigue show an increase in
the amount of work done, while those taken during the later
stages show a diminution. Professor Mosso in his work on
fatigue gives two ergographic tracings performed involuntarily
by the finger of Dr. Maggiora before and after examining twelve
students in hygiene for their degree in the University of Turin.
The muscular contractions were induced every two seconds by
electrical stimulation of the median nerve near the axilla. The
effect of the examinations, which lasted three hours and a half,
was to reduce the number of contractions from fifty-four to
twelve, the initial contraction of the second tracing being less
than three-quarters of the height of that of the first. Similar
results are obtained by the voluntary method.
From the latter observations it might be inferred that all
fatigue is muscular in origin, fatigue-products during mental
exertion being formed as a result presumably of that muscular
strain which is a constant concomitant of the act of attention.
In other words there is no such thing as primary fatigue of the
nervous system.
That this is not the case, however, and that the problem is not
so simple as it appears at first sight, is shown by certain experi-
ments by Sherrington on the scratch-reflex of a spinal dog.
There is a large area of skin covering the ribs of a spinal dog,
mechanical or electrical stimulation of which produces a scratch-
ing movement of the hind-limb of the same side. Now this
reflex can be fatigued in a few minutes by persistent stimula-
tion of a given spot within the said receptive area. That this
fatigue is of nervous and not of muscular origin is shown by
the fact that the scratching will start afresh if the stimulation be
transferred to another spot a few centimetres away, but within
the same receptive area. This demonstrates further that, so
far as the nervous system is concerned, the receptive synapse
tends to become fatigued more readily than the efferent (motor)
synapse. Sherrington also points out that nervous fatigue passes
off much more rapidly than muscular fatigue, the scratch-reflex
being as brisk as ever again after the lapse of a few minutes.
The following method of obtaining a direct curve of intellectual
fatigue in man has been devised by Weygandt. The necessary
apparatus consists of a clock which rings a bell once a minute
(or other prearranged time), a sheet of numerical figures arranged
in vertical and horizontal lines, and a pencil. The clock is set
going and the person under observation takes the pencil. When
96 MIND AND ITS DISORDERS
the bell rings he starts adding up to the first vertical column as
quickly as he can. When the bell rings again he ceases adding
up the first column, draws a line, writes down the result so far
as he has gone and immediately starts on the second column.
The same process is repeated, and when the bell rings a third time
he passes on to the third column, and so on. The experiment
is complete when about twenty columns have been added. On
examination of the resulting curve it is found that the added
portions of the columns at first increase in length; then, as the
secondary effect of fatigue sets in, the length of the added portions
gradually diminishes. Mistakes also occur more frequently in
the later columns.
The study of fatigue is yet in its infancy, but we are justified
in asserting that all its phenomena are due to the formation
of paralyzing products within the muscular, and perhaps the
nervous, system; and it need be no matter for surprise that the
initial action of these products is stimulating in its nature, when
we reflect that the same is true of many of the sedative drugs
we possess, ¢.g., chloroform, ether, morphia, cannabis indica
and alcohol.
SLEEP.
And after fatigue, rest! Sleep is the condition of partial or
complete unconsciousness which normally recurs once in twenty-
four hours and occupies about one-third of that time.
Sleep abolishes fatigue; in other words, it helps to rid the
organism of fatigue-products. In what way it does so, whether
by destruction or excretion, 1s unknown.
Sleep varies in its soundness or depth. By awakening sleepers
with the noise of brass balls falling from various heights on an
open board, it has been shown that sleep is deepest about an
hour and a quarter after its onset and that its depth may be
represented by a curve as shown in Fig. 20.
All the vital functions are reduced during sleep; the pulse and
respiration, which is mainly diaphragmatic, are slowed and the
excretion of urine and of carbon dioxide is diminished. Heat-
production is at its lowest; we therefore require to be more
warmly covered than during waking hours. The heat-produc-
tion during sleep is roughly 4o kilo-calories per hour as against
roo during rest, 150 during moderate movement and 300 during
exercise. The brain is partially anemic during sleep as is
evidenced by the depression over the anterior fontanelle of
infants and over trephine holes in adults and by certain experi-
SLEEP 97
mental observations on lower animals. The optic disc is pale,
the retinal arteries small and veins large. The voluntary muscles
are relaxed and the superficial and tendon reflexes absent. The
muscular tone of the flexors of the fingers is perhaps increased,
that of the orbicularis palpebrarum is undoubtedly increased
while the levator palpebre superioris is relaxed. If the eyelids
be raised it will be seen that the eyeballs are rotated upwards and
that. they have a constant slow lateral movement, the two globes
moving independently of one another. The pupils are contracted.
The tendency of young infants and of the insane to fall out of
bed is a curious illustration of the general principles of evolution
and dissolution.
25
5 ome
0
mei cee oF 4) 6G GT
Fic, 20.—SLEEP CHART (AFTER E, W. SCRIPTURE).
Horizontal scale gives hours after falling asleep. Vertical scale gives
energy of falling ball in thousandths of gramme-centimetres (weight
of ball x height of fall). Although it cannot be said that the intensity
of the sound was proportional to the energy of the falling ball,yet the
scale can serve as a fair approximation to a scale of sound-intensities.
It would appear that it is possible for isolated portions of the
mind to remain awake while the remainder sleeps. According
to Professor James, a mother sleeping soundly by her sick child,
in spite of the noise of traffic and of people talking in the room,
awakens to full consciousness at the feeblest cry of her sleeping
babe.
The act of going to sleep is normally an auto-suggestion. We
place ourselves in a comfortable position, adjust our eyes etc.
to the attitude of sleep, think of going to sleep and in a few
minutes ‘sleep results. If a person retires to bed thinking that
he will not sleep, the result is that he lies awake for hours.
According to Professor Baldwin self-consciousness is inimical
fi
98 MIND AND ITS DISORDERS
to sleep; the idea that J am going to sleep is not so soporific as
the idea that someone else is going to sleep.
The condition of the neurons during sleep is of great interest.
It has been found that excessive activity causes disappearance,
at least to a considerable extent, of the chromatoplasm from
nerve-cells and that rest allows it to reaccumulate. It has also
been demonstrated experimentally that the gemmules are pro-
truded during sleep and retracted during activity (Lugaro). It
may therefore be assumed that, during the process of going to
sleep, the gemmules are gradually being protruded. It is con-
ceivable that during this stage a new interneuronic (synaptic)
association occasionally occurs for the first time. Now in con-
sidering automatic action we saw reason for the belief that the
occurrence of new or unusual synaptic connections between the
neurons induced instinctive or reflex attention; and we have
further seen that an ordinary “start ’’ is nothing but a special
form of reflex attention. We thus see a possible explanation of
the “start ’’ which, during the process of going to sleep, occurs
so frequently during the first half of life. When once the neurons
are all connected up, attention to external environment is no
longer possible and all slight sensations pass unnoticed.
There can be no psychology of deep dreamless sleep. When a
person is unconscious, all mental operations are in abeyance:
what more can be said? In very light sleep, however, when we
are not quite fully awake, there is a marked tendency to the
formation of hallucinations, especially visual. This condition
is known as the hypnagogic state, and the hallucinations as
hypnagogic hallucinations. Coriat reports the occurrence of
catalepsy and what he calls “ nocturnal paralysis ’’ in this state.
As a result of such observations various theories of sleep have
been formulated, all of which contain an element of truth.
These are (1) that it is caused by cerebral anemia; (2) that it is
due to a general linking up of neurons, so that synaptic resistance
is reduced to a minimum; (3) that it is induced by intoxication
of the nervous system by the products of fatigue; (4) that it is
to be ascribed to lack of oxygen and excess of carbonic acid
in the brain; (5) that it is owing to the absence of distracting
external stimuli; (6) that it is an instinctive reaction of defence
of the organism against fatigue, evolved by processes of natural
selection. (1) and (2) should probably not be regarded as causes,
but rather as effects or concomitant features; while experience
in the fighting-line during the War has proved (5) to be an un-
essential factor. Our conclusion is, therefore, that sleep is the
DREAM DISTORTION | 99
result of an instinct to place ourselves in conditions favourable
to its production. Chief among these is a situation or attitude
depriving the organism of oxygen or supplying it with an excess
of carbon dioxide. Birds tuck their heads under their wings,
rabbits seek their stuffy burrows, other animals curl up and bury
their noses in soft parts of the abdomen and man buries his
face in the bedclothes. Fatigue, which is partly due to the
accumulation of carbon dioxide in the tissues, may render such
attitudes unnecessary, and it seems clear that (3) and (4) are
really the same thing. In support of the view that sleep is an
instinct there is plenty of psycho-analytic evidence to show that
a sleeper wishes during sleep to continue sleeping.
Dreams.—During sleep, but probably not during deep sleep,
most people are subject to dreams. A few people never have a
dream in their lives. Dream-perceptions are mostly visual; next
in order of frequency come auditory perceptions. Visual dream-
perceptions are usually coloured, but it is noteworthy that un-
saturated colours and intermediate shades of colour are unusual
in dreams. Olfactory hallucinations are also extremely un-
common in dreams, and gustatory sensations practically never
occur. If we dream we are at dinner, we see the various dishes
but very rarely eat anything; and if we do, we find invariably
that the dainty is entirely devoid of taste. When dream-smells
occur it appears to be the rule for them to persist for a short
time after waking.
Dream-movements also have their characteristics. Apart
from flying and floating sensations in which the body moves as
a whole, movements at the small peripheral joints are easy of
performance, while movements at the large proximal joints are
difficult. I do not refer to actual (somnambulistic) movements
performed during sleep. We can waltz or spring and we can
write or sew with ease; but if we attempt to strike or kick an
adversary, we can get no force into the blow: it is like trying to
kick him when we are immersed in water. It was suggested by
Dr. Hughlings Jackson that this is due to a larger representation
in the frontal lobes of peripheral than of proximal movements.
The psycho-analytical interpretation of the phenomenon would
be that there is an absence of any unconscious wish to get force
into the blow, which may or may not symbolize some other form
of activity.
In past ages, and even to-day among ignorant and unprincipled
charlatans, dreams have served as a basis for prophecy, necro-
mancy, telepathy and even religion; but the researches of Freud
100 MIND AND ITS DISORDERS
and many of his followers have completely robbed dreams of their
mystery. It is now definitely established that they are nothing
more than the imagined fulfilment of unconscious or, less com-
monly, conscious wishes, memories of our experiences during
waking hours being utilized in the process.
Various elements of the dream are doubtless distorted out of
all recognition, so much so, indeed, that events in the dream
frequently seem to be the very opposite of what they really
represent. Such distortion varies in different individuals; but
we may state generally that it is much greater when the wish
fulfilled is unacceptable to waking consciousness, the alert
mind unwilling to admit the desire, and, in fact, the wish has
been repressed into the unconscious. Sexual desires are the most
repressed of all, and therefore they are the most disguised.
Indeed, few people unfamiliar with psycho-analysis would admit
that their dreams have any sexual meaning whatever; but, as a
matter of fact, psycho-analytical investigation, to be discussed in
a subsequent chapter, teaches us that there is a sexual element
in nearly every dream.
We have, then, to recognize that there is a manifest and a
latent content of every dream. The manifest content includes
the incidents of the dream as they might be related at the break-
fast-table next morning; the latent content is the deeper meaning
which is ascertained by studying the mental associations of
various items of the dream, and this always turns out to be a
wish fulfilled. This is the real object and purpose of dreaming,
to gratify unconscious desires which can obtain gratification in
no other way without producing mental disorder, while the dis-
tortion of the dream serves as the guardian of sleep. When the
deeper meaning, the latent content, of a dream is insufficiently
disguised, the dreamer awakes.
The chief mechanisms of the distortion are four, viz., Displace-
ment, Condensation, Symbolization and Dramatization.
Displacement.—The dream substitutes one person for another
or one idea for another. For example, a passing friend of years
ago who has passed out of one’s life always stands for somebody
of intimate biological importance to the dreamer. Moreover,
apparently unimportant items of a dream are commonly the most
significant, as also are vague details, perhaps forgotten at first,
but subsequently remembered, or remembered at first, but
subsequently forgotten.
Condensation.—Most elements in a dream comprise many
unconscious thoughts. For example, a patient of mine dreamt
HYPNOTISM Io!
that she was in Ashley Road in a provincial town in which her
mother-in-law lived. Ash referred to Dr. Ash, who had treated
her by hypnotism—“ley”’ referred to the River Lee, on whose
banks she contemplated building a house, and also to Leigh
Denny, a character in a novel she had read, who stood for her
husband. Unrecognizable people are usually condensations of
two or more persons—the eyes of one, the clothes of another,
some characteristic pose of a third, and so forth.
Symbolization.—Even in everyday life symbolism is in common
use. “A bed of roses’ symbolizes freedom from care, “‘ thorns ”’
symbolize trouble, “red tape’”’ symbolizes officialism and the
national flag the nation. Such symbolism is utilized much more
freely in dreams. Walking with a person means agreement with
him or payment of homage to him (“‘ Enoch walked with God’’).
Hollow objects (houses, boxes etc.) symbolize the female body.
Long objects (sticks, swords, pistols, syringes etc.) symbolize
the male genital organ, as also do musical iustruments. Emperor
and Empress, King and Queen, stand for father and mother, and
so forth. Symbolization is a subject which might well claim a
chapter for itself, or even a book; but it is better for the student
_ to discover symbolisms by experience.
Dramatization-The dream is presented in a more or less
dramatic form by introducing and arranging people, objects and
situations in such a way that they will fit into the picture. For
the same reason past and future both become the present.
In conclusion of this brief epitome of dream psychology, let
me repeat that the latent content of a dream is always the fulfil-
ment of a conscious or, more commonly, an unconscious wish.
A dream is not interpreted until this wish is discovered.
Hypnosis.—In the special form of sleep known as hypnosis the
subject has a vivid idea that he is going to sleep under the
operator’s influence, and it is the duty of the operator to en-
courage this idea by means of “ passes’, incantations, stroking
the skin etc. If the subject has an idea that the operator cannot
send him to sleep, the latter will undoubtedly fail. It is clear
therefore that hypnosis is in reality an auto-suggestion just as
ordinary sleep is.
There are roughly three stages or degrees of hypnosis which
merge into one another. The first is that of “ flexibilitas cerea ”’,
in which the limbs are rigid but may easily be moulded into
any attitude by the operator. In this stage there is anesthesia
of certain portions of the skin and the subject is extremely sus-
ceptible to suggestion. In the second stage, that of “‘ lethargy ”’,
I02 MIND AND ITS DISORDERS
the whole body is flaccid and the subject appears to be entirely
unconscious. The third stage is that of ““somnambulism’”’, in
which the subject is again extremely susceptible to suggestion
and there is exaltation of the senses with disturbance of memory.
In this stage mere suggestion from the operator suffices to enable
the subject to perform actions which are impossible to him during
his waking state. On awakening he has no memory of these
actions; yet, on the other hand, suggestions, given during
hypnosis, of actions to be performed subsequently at a given
time when he is awake, are satisfactorily carried out without
his being able to give any reason for such actions. Moreover,
the hypnotized subject is able to remember incidents which he is
unable to recall in his normal state. By hypnotism, therefore,
we are able to broach the unconscious in order to discover hidden
memories and to influence subsequent conduct of a patient.
Indeed the very lowest levels of the nervous system may be
affected by this means; certain hypnotists have succeeded, for
example, in raising a blister on a subject by applying a piece of
stamp paper and suggesting that it is a piece of charta
epispastica.
Not that the lowest level of the nervous system is immune
from psychical influence in the normal state, for the so-called
““ MENTAL REFLEXES ”’ prove the contrary. As Pawlow has demon-
strated, a dog secretes limpid saliva if you show him a biscuit,
but viscid saliva if you show him a bowl of porridge. The
nipples of a woman become erect if she thinks of suckling her
child and sexual thoughts produce specific vaso-dilatation. If,
in a dim light, you think of looking into a dark cellar, the pupils
dilate and if, without moving, you then think of looking at
the setting sun, the pupils contract. Again, let a person fixate
a spot on the wall while the light of a lamp falls on his eyes
from the periphery of his visual field and note the size of his
pupils; then tell him to direct his attention to the light without
moving his eyes, and his pupils will contract. Other examples
might be cited, but these will suffice to confirm the important
fact that the highest functions of the nervous system may actuate
the reflexes of the lowest level.
Several sittings are requisite in most cases before a person can
be satisfactorily hypnotized; but when once hypnotism has been
induced it is an easy matter to hypnotize him on subsequent
occasions. For this reason an operator should always “‘lock’”’ ~
his cases by the suggestion that the subject cannot be hypnotized
by anyone else, lest he get into the hands of some unscrupulous
HYPNOTISM I03
person. A hypnotized subject, if left to himself without any
suggestion, falls into a natural sleep and then wakes up.
The phenomena of hypnosis, wonderful as they are, do not
merit the shroud of mystery in which they have been enveloped.
I believe they could all be found at times in ordinary sleep.
In both conditions the attention is purely instinctive and lacks
the “inertia ’’ of waking attention; and there is much the same
disturbance of memory in both. Somnambulism occurs in deep
hypnosis, just as it occurs in deep sleep about an hour after
retiring to bed. And with regard to the suggestion business,
we are all as susceptible to suggestion as we can well be during
our waking moments; the ordinary somnambulist is only more
so. When told to retire from a dangerous position and to return
to bed, he does so immediately. Whether he would perform such
tricks as are done by the victims of professional hypnotists, if
they were suggested to him, I am unable to say; probably he
would.
It must be admitted that, for successful hypnosis, the patient
must have confidence in the hypnotist; and Ferenczi has shown
that this state of confident rapport is not unattended by feelings
_of a more positive kind, such as affection, friendship and even
love. This explains why patients treated by hypnotism are
liable to develop undue dependence on their physician.
DEAR Ten
THE SENTIMENTS.
THE sentiments are somewhat allied to the emotions. An
emotion is a sensation-complex resulting from an involuntary
reaction to a percept or idea; a sentiment is a sensation-complex
which arises when judgment is passed on the way in which
a percept or idea affects the feelings. In the former case atten-
tion to the percept or idea is instinctive; in the latter it is volun-
tary. Emotion is a less conscious process than sentiment.
There are three kinds of sentiment: the esthetic, the moral
and the intellectual. The esthetic sentiment arises in associa-
tion with the passing of a judgment upon a thing, sometimes
upon an action, the moral when judgment is passed on an
action; and the intellectual when judgment is passed on a
judgment.
The esthetic sentiments form the largest group. The judg-
ments formed in association with these answer the question:
Is this beautiful or ugly? They include the sentiments of
beauty, ugliness, comedy and tragedy. A thorough investiga-
tion of the first two of these would comprise a study of all the
laws relating to art. It would include a study of symmetry,
asymmetry and curves; of the combination and contrasting of
colours; of the movements of dancing; of the most pleasing
combinations of tones in music, of the formation of melodies
and other sequences (avoiding consecutive fifths and octaves),
of fugue, counterpoint and orchestration. Moreover, we would
have to investigate those unorthodox forms of art which break
recognized rules and forms in order to give enhanced pleasure.
Indeed, a psychological study of the reasons why modern artists
and musical composers have regressed to the primitive (cubism,
futurism, negro music, studied discord without attempt at sub-
sequent resolution etc.) would prove a most interesting chapter.
Finally we would have to analyze the biological reasons why
certain of these forms give greater or less pleasure than others;
but all this, despite its importance, would obviously be outside
the province of this manual.
104
THE SENTIMENTS 105
The study of comedy and tragedy is perhaps more important.
Tragedy as such has received but little attention from psycho-
logists, although many of the characters in tragedy have been
analyzed very thoroughly. On the other hand, volumes have
been written about comedy and the comic. By comedy we mean
a combination of the beautiful with the ludicrous, by tragedy a
combination of the beautiful with the sad. This meaning of
_ comedy and tragedy differs somewhat from the popular notion
of these sentiments. We read on the evening placards of a
“ tragic’? murder in Whitechapel when the paper contains an
account of some loathsome incident totally devoid of any of the
beautiful touches of true tragedy. Possibly such an incident
arouses in a morbid individual some sentiment analogous to that
of true tragedy as experienced by a man of finer feelings when
he reads Shakespeare’s ‘‘ Romeo and Juliet’. Similarly common
folk regard coarse and disgusting stories, devoid of wit, as comic
when there is no trace in them of the beautiful touches of true
comedy. By the way, the underlying reason why these may
give rise to hilarity is that they are symbolized sexual aggressions
against the person to whom they are related.
The essence of comedy is sudden incongruity. If you see a
child wearing his father’s hat, there is something absurdly
ludicrous in the picture; but if you expect to see him in it and
have already formed some idea of how he would look, most of
the comedy of the situation disappears. The first time you hear
of the famous general who pounced out of his front door upon
a lady visitor in response to what he believed to be a runaway
knock the comedy of the situation is much more striking than
when the story is repeated, although we still appreciate the
incongruity. The reason why we feel bored by so-called “ chest-
nuts’ is that their incongruity lacks the suddenness which is
necessary to mirth.
Premeditated comicalities of speech, such as are produced by
a play on words, puns, nonsensical remarks, double meanings,
ambiguities and a host of other factors, are known as “ wit ”’;
and Freud has shown in a masterly work that all wit is of un-
conscious origin and that the underlying mechanisms are to a
large extent identical with those of dreams.
Laughter, which is regarded as the expression of the emotion
corresponding to the sentiment “‘ comedy’, is somewhat of a
puzzle to psychologists. It appears to be evolved from the
smile which makes its appearance in the infant before the laugh;
and the elementary form of both is supposed to be the reaction
To6 MIND AND ITS DISORDERS
to tickling. Tickling, in turn, is regarded as playing at attack.
Laughter is therefore an expression intimately associated with
play. It is not perfectly clear what is the teleological value of
laughter, but the following has been suggested :
The essence of children’s play is make-believe, pretending to
do that which in after-life they will be called upon to do in
reality. In other words play is the instinctive exercising of
muscles in preparation for the work of real life. And when in
play a puppy flies at its mother’s throat or a human infant
beats its mother, smiling or laughter on the part of the mother
will indicate to the offspring that it has not gone too far. A
change in the mother’s expression will then indicate danger and
cause the offspring to cease striking her.
Other psychologists think that we laugh to avoid being miser
able, that laughter is an antidote to melancholy or to sympathy.
A little consideration shows that there is a good deal to be said
for such views. Why is it that some people laugh till they cry ?
Why does the sight of a man chasing his hat over the mud on
a windy day provoke laughter ? Why does a child laugh when
tickled and struggle to escape at the same time ?
The moral sentiments include the social, the ethical and the
religious. The judgments formed in association with these
sentiments answer the questions: “Is this antisocial?” “Is
this good or bad for the individual or for the race ?”’ “ Is this in
accordance with the Divine Will?’’ The common characteristic
of actions which are judged as moral is that they involve the
foregoing of present pleasure for the purpose of enhanced benefit
or diminished inconvenience in the future to the individual or the
race. Immorality arises from deficient voluntary control of the
baser instincts. Fundamentally morality is a tendency to comply
with the wishes of one’s fellows; but what those wishes are has
to be taught to and learned anew by every individual during
his childhood. In due course this acquires the force of an instinct,
which Freud has called the ego-instinct. I hope that this digres-
sion will not cause the reader to confuse the moral sentiments
with the ego-nstinets.
The judgments formed in connection with the intellectual
sentiments answer the question: “‘Is this proposition true or
false ?’’ ‘“‘ Am I to believe it or not ?”’
Belief.—Every judgment implies the possibility of an alterna-
tive: the judgment “ This is so’”’ implies the possibility of the
judgment “ That is not so”’ and it is left to the individual to
accept one or other of these. Belief in the latter implies dis-
BELIEFS 107
belief in the former. Belief and disbelief are therefore the
same mental process. Their common antagonist is doubt, which
is an oscillation between belief and disbelief and gives its charac-
teristic emotional tone in sensations derived from muscular
tension and restlessness. The emotional tone or belief or dis-
belief is that of relief, dependent upon relaxation of the muscular
tension associated with doubt.
Under ordinary circumstances a judgment is believed when it
does not contradict any other judgment which we have formed;
it then arouses the emotion of conviction, which 7s belief. The
final court of appeal is that of the organs of special sense. If
we can see a thing we perceive it as a reality and believe it. Yet
who is to say what is real and what is imaginary in view of the
cases of double consciousness or of those of hallucinations of
vision ? These latter are so real to the patient that he throws
his boots at the objects he sees. And what becomes of reality
when a sleeper dreams “‘ This is no dream; this is reality ’’ ?
There are three forms of belief, which may be termed respec-
tively (1) rational belief, (2) intuitive belief and (3) belief by
suggestion. In the first form, rational belief, the individual
examines the evidence for and against a given judgment, wherever
possible referring each piece of evidence, as it arises, to his
organs of special sense. When, by such a process of reason-
ing, a person arrives at a conclusion, his belief may be termed
“rational ’’.
It is quite possible for a person to have a rational belief in
an erroneous judgment, some fallacies having crept into his
train of reasoning; but this does not affect the psychical nature
of his belief. The late eminent neurologist, Dr. Charlton Bastian,
believed that the spontaneous generation of living organisms
goes on at the present day. Most, if not all, other scientific
men believe Dr. Bastian’s judgment to be erroneous in this
matter; but he arrived at his conclusions by processes of experi-
ment and reasoning. His belief in them was therefore rational.
In other cases a person believes in a given judgment without
going through any such process as the above. He or, more
commonly, she feels that such and such is the case and, merely
on account of the feeling, believes it to be so. One of the most
common examples of this form of belief occurs when “ the wish
is father to the thought ’’. A woman, with a distant relation
whom she loves, may suddenly become convinced that evil has
befallen her dear one; and she believes it. Such beliefs as
these have their basis in the unconscious which induces some
To8 MIND AND ITS DISORDERS
emotional tone of feeling. For this reason, they may be called
“instinctive or intuitive beliefs”. They are by no means
always erroneous; but their nature is such that they must be
banished from most scientific thought. Intuitive belief is, how-
ever, frequently useful in psycho-analytical investigation. The
subject feels that there is a connection in his mind between one
idea and another, although for the moment the nature of the
connection cannot be discerned; yet, as the analysis proceeds,
the nature of the connection is ultimately discovered and the
original intuition justified.
“ Belief by suggestion’ is unquestioning belief in a given
statement made to the individual. When someone tells me
that Mrs. Jones died last night, offhand I believe it although
Mrs. Jones appeared to me last evening to be in the best of
health. Superstitious beliefs are usually of this nature; others
are symbolic of a deeply hidden unconscious wish common to the
whole human race. In one form of practical joking, “ pulling
a person’s leg ’’, commonly practised on April I in each year,
advantage is taken of this tendency to “ believe by suggestion ”’.
,
(elie Eee Ns,
LANGUAGE,
In studying the emotions we concluded that their expression
was their very essence; a careful observer can tell another
person’s feelings by noting his expression. It does not always
require careful observation; when a fox flies from his hunters
he expresses terror in an unmistakable manner. The contention
of those who encourage this form of “ sport ’’, that the fox enjoys
it, is absurd; the fox is telling them the whole time in his own
language that he is terrified.
The above might be called an example of instinctive language.
It is the language of “ gesture”. But let us examine some
forms of intellectual language in which an animal voluntarily
expresses his thoughts. When a dog sees you eating a biscuit
and sits up on his haunches, he is telling you that he would like
a piece of it; when a foreigner, unfamiliar with the English
tongue, walks into a restaurant and points to his mouth, he is
asking for food in the same language as the dog; and when a
man beckons, he is saying in the same language “‘ Come here ”’
Such language has been called “‘ pantomime ”’.
A much more convenient form of language is one in which
sound plays an important part, because it serves to attract
another’s attention when he is not looking your way. Many
animals have a very limited sound language, generally of the
instinctive variety ; for example, a sheep has two such words, viz.,
‘“Baa’’ meaning (perhaps) “I am in distress’’ and “‘ Swish ”’
meaning “‘ Look out! there’s someone coming ’’. Ants are in-
capable of making much sound and I think I have read some-
where that they are deaf; accordingly they have to convey their
ideas to one another in a tactile language, by means of their
antenne.
Man has the advantage of all these animals in having a lan-
guage of words. The advantage lies in the fact that words
can be expressed by means of sound (spoken language) or light
(written language) or even by the sense of touch (language of
109
IIO MIND AND ITS DISORDERS
those who are both blind and deaf). Words are the symbols
of our mentation and are to be regarded as psychical things
whose physical basis is situated in the motor centre for speech
in the third left frontal convolution of the brain.* It is there
that the ideational centre for the action of speech is situated;
it is there that word and sentence motor-ideas arise. But we
have already seen that our idea of any object, for example a
violin, may be visual or auditory as well as motor; and the
same is the case with words. We may have a visual idea of a
word as it is written or printed or we may have an auditory idea
of the word as it sounds when spoken.
We know that the visual idea of a word is formed (in right-
handed people) in the neighbourhood of the left angular gyrus.
If the left angular gyrus of a right-handed man be damaged
he can see a printed word as well as any of us, but the word has
for him no ideational content; it might as well be Chinese.
Such a patient is said to be suffering from word-blindness.
Word-vision is only a special department of visual perception
and the word-vision centre behind the left angular gyrus is only
a part of the area for visual-perception in general. The right
occipital lobe participates with the left in the perception of
objects other than words.
Similarly the word-hearing centre is a part of the centre for
auditory perception in general and is situated in the first temporo-
sphenoidal convolution. The corresponding convolution on the
right side participates with it in the perception of sounds other
_ than words and perhaps of music. The physical basis of per-
ception of such sounds as that of a soda-water siphon in action
or of paper being torn lies in the first temporo-sphenoidal con-
volution of both cerebral hemispheres.
Lastly there is a motor centre for written language, situated
in the neighbourhood of the “ hand-area’’, anterior to the left
fissure of Rolando. Patients unable to write, on account of
a lesion of the writing centre, are said to be suffering from
“agraphia’’. Loss of the motor-idea of writing is difficult to
determine in these patients because of their physical disability
(paralysis of the right arm and hand).
* Marie threw some doubt on the existence of an ideomotor centre for
speech. He believed motor aphasia to be nothing more than anarthria
(defective articulation) plus acquired defect of intelligence. Apart from
the fact that the existence of such a centre brings speech into line with
other movements, aphasia being nothing more than a special form of
apraxia, Marie’s hypothesis does not account for the clear enunciation of
“ recurring utterances ’’ by aphasic patients.
SPEECH Diy ia
Speech, then, is a psychical thing consisting of word-ideas
which are our symbols for other ideas. I wish particularly to
emphasize this point, because there appears to be a tendency
to confuse speech with articulation, which belongs to a lower
order of things altogether. Occasionally we hear it said that
a person’s “‘speech’’ is tremulous, when it is meant that his
“articulation ’’ is tremulous. The distinction is not merely
~ academic; the student who confounds articulation with speech
must of necessity confuse their physical bases. The physical
basis of speech is, as we have seen, in the ideational (association)
centres; the physical basis of articulation is in the cortical
projection areas and in the hypoglossal nucleus. In the exercise
of our profession we are largely dependent on the word-symbols
of our patients in our endeavours to arrive at a correct diag-
nosis; but if we confuse the physical (articulation) with the
psychical (speech), we make a false start and lay a foundation
for erronecus diagnosis.
LANGUAGE AND THE UNCONSCIOUS.
‘
Reference has already been made to “ automatic writing ’’,
which is the best recognized variety of unconscious language;
and it has been mentioned at the end of the chapter on Action
that slips of the tongue and pen are the expression of unconscious
wishes.
I will here content myself with a personal example of a slip
of the pen. I was asked to open a discussion on psycho-analysis
before an audience which would probably be very antagonistic.
After much hesitation, I finally consented by letter, should my
correspondent “ get up the debate’’; but in my reply a slip of
the pen occurred and I wrote “ give’’ instead of “ get ’’, thus
betraying the unconscious wish. Of course I had to rewrite the
letter.
CHAPTER XI.
THE EGO,
As conscious individuals each of us recognizes that there is in
him something he calls “I” or, psychologically, his “ Ego ”
Each one of us draws a distinction between “ self’’ and “ not-
self’’, ““me’’ and “ not-me’’, the consciously thinking subject
which perceives, experiences pleasure and pain, seeks information
and strives for ideals, as opposed to the objects perceived, the
pleasure and pain experienced, the information which is sought
and the ideals which are pursued.
Of what does this ego consist ? Many psychologists have made
rather a mystery of the conception. Some speak of an ego-
complex as if to imply that the ego feeling is unconscious. To
be sure, the concept of one’s own personality is not always
present in the conscious, but it can easily be raised piecemeal
into consciousness. It is therefore to be regarded as persistently
preconscious, for the whole content of the ego can never be in
full consciousness at the same moment. At any rate, it is not
unconscious, and it is therefore wrong to speak of it as a complex.
Let us attempt to trace this ego-sense from its very beginning.
The child asleep in its mother’s womb certainly has no sense
of its own personality; but the frightful experience of being born
and the intense terror inspired thereby must of necessity give
the child some initial sense of its own individuality. After the
birth is all over, the baby constantly tends to return to its primi-
tive state of sleep. This is only interrupted by feelings of un-
satisfied desire, the want of food, the desire to evacuate the
bowels or to pass urine or, in certain circumstances, the wish for
relief from partial suffocation or from stimulation of the respira-
tory tract in some other way. It would therefore appear that
the ego-sense is engendered, at any rate in the first instance, by
a feeling of dissatisfaction or discontent, otherwise by desire,*
wishes, aspirations and all that these connote—enterprise,
venture, striving and activity.
Let us here digress for a moment to combat the notion that
* I do not say ungratified desire because desire ceases aS soon as it is
gratified.
112
MAN AND WOMAN ned ES
our material body plays an important part in our concept of self.
It is true that the self idea is primarily dependent on physical
sensation, as are all other ideas and concepts; but nobody at any
time uses the word “I ”’ in the sense of “‘ my physical body ”’.
It never occurs to us that we leave part of our ego at the hair-
dresser’s, at the dentist’s or at the surgeon’s. Moreover, a child
will offer its toe a biscuit and a dog will run after its own tail.
From the four vegetative wishes above mentioned (stimulation
of the mouth, the anus, the neck of the bladder and the respiratory
tract), that which at first sight would appear to bring the child
into relationship with the external world is the first: sucking the
mother’s breast; yet the new-born child knows nothing of its
mother. Placed into sufficient contiguity to the breast a perfectly
healthy new-born infant will seek the nipple and suck it. Itis
usually quite unnecessary for the mother to place it in the baby’s
mouth. The baby accepts the mother’s breast as part of itself and,
on further consideration of the matter, we find that what the
child considers as not-self is anything or anybody that opposes the
gratification of its wishes. So far, therefore, our definition of the
ego would be “ that which experiences desire and gratifies it ”’.
As life advances our wishes become more numerous and more
complicated. Excluding the wish to avoid things, the “ desire
of aversion ’”’, our desires are mainly those of possession and of
achievement. Those possessions which are most closely bound
up with the ego are those which are in closest relationship with
the person, such as our clothes and things, for which we have
striven and obtained by our own efforts. And as to our achieve-
ments, these are what maintain a sense of self-esteem (Narcism),
while adverse criticism of our work is a severe blow to our ego-
sense, to our Narcism.
The ego, then, is very dear to each one of us. When a man
says “I would like to be Lord Leverhulme ’’, he only means
that he would like to be possessed of that man’s wealth and
capabilities. He does not wish to change his identity. That
would involve the obliteration of the memory of his past life,
of old friends and countless incidents whose recall is one of the
pleasures of existence. But that is not all which renders the con-
cept self dear to us; for, in cases of double personality, in which
the subject has entirely changed his identity through disease, he
has no desire to return to his former ego. Indeed, he would not
know of its existence but for some circumstantial evidence.
A man’s name, which is a symbol of his personality, makes a
large contribution to his ego-sense. The surname connotes his
8
II4 MIND AND ITS DISORDERS
relationship to his parents and other members of his. family,
identifies him with them and reminds him of their outstanding
characteristics. It is, therefore, no small matter for an indi-
vidual to have been an illegitimate child or to have a convict
for one of his close relatives. And if a man’s Christian name or
surname has a meaning or connotation in the ordinary language, it
is remarkable how frequently this tends to determine his interests.
Our conclusion is therefore that the ego is a recombination of
abstractions from many individualities. The City Company
Promoter has totally distinct individualities when he is doing a
cross-word puzzle at home, bathing in the sea or reading the
lessons at church; and his ego is a recombination of abstractions
from all such personalities. It is difficult to think of the ego in
terms of the intellect, perception, judgment, knowledge and
similar functions exclusively; they may help to build it, but the
most important factors are the person’s wishes and feelings.
Let us here revert to what was said at the beginning of this
chapter, viz., that the ego is not unconscious. Indeed no part
of this concept lies in the unconscious, but it may be admitted
that it is mainly preconscious and, when we come to think of it,
this appears to raise the question whether the preconscious
contains anything that is not a part of the ego. Is not the ego
more or less identical with the preconscious ? During childhood
this is true enough while the character is being moulded by the
parents or their surrogates; but after this period every individual
comes to rule himself—or ought to do so—by absorbing this
parental influence into his own mind. This function is what
Freud has called the Ego-ideal or Super-ego, which is partly
conscious and preconscious (conscience) but also in part uncon-
scious. The constitution of the personality may therefore be
diagrammatically represented thus:
Conscious
Conscience
Preconscious Ego
°
80
fx)
H
Unconscious Id &.
=}
n
The Id is the name given to that part of the unconscious which
contains repressed desires of a libidinous nature,
MAN AND WOMAN II5
In childhood narcism or self-love is directed toward the real
ego. In later life it is transferred to the Ego-ideal or Super-ego.
A feeling of guilt or inferiority without obvious cause is due
to conflict between the Super-ego and the Id, as also are self-
accusations and delusions of being watched in the psychoses.
PERSONAL DIFFERENCES.
In the above account of the mental constitution of a normal
individual we have already seen that certain differences exist
between people. They differ in their ideational type, in their
inherited tendencies and in the acquired tendencies which educa-
tion and environment have given them. Some have a preference
for saturated colours, others for neutral tints, and so forth.
It has further been determined that sensation is more acute in
some people than in others. For example, sensibility to touch
and pain is keener in town than in country folk, in whites than
in negroes, among educated classes than among the lower and
probably in men than in women, although Lombroso and Jastrow
obtained opposite results in comparing the sexes. Similarly
men possess a keener sense of smell and of hearing than women.
With Galton’s whistle it has been found that, as a general rule,
men can hear the shrillest notes more often than women. On
the other hand, the sense of taste is keener in women than in
men, except for salt. There appears to be no marked sexual
difference in the keenness of healthy vision.
Woman, then, is on the whole less sensitive than man. On
the other hand, a woman’s motor response to a stimulus is more
ready than man’s; she is less sensitive but more irritable, or
rather, affectable. Insensitiveness and affectability, however, do
not invariably go hand in hand, for town folk are more affectable
than country folk and whites are more affectable than negroes;
while the lower classes are more affectable than the educated.
The general character of motor reaction in woman as com-
pared with that in man has probably some connection with the
relative muscular weakness of woman. Riccardi found that, in
a series of attempts to exhibit their maximum force with a
dynamometer, this was attained by the majority of women at
the first attempt, by the majority of men at the second with
the right hand; but, with the weak left hand, both men and
women attained their maximum on the first attempt.
Woman is quick of perception and ready ofaction. She takes in
a situation at a glance and acts upon it; man is more deliberate.
It is always the woman who retrieves a compromising situation.
LLO MIND AND ITS DISORDERS
Fatigue shows itself in women more readily than in men.
This may easily be demonstrated by getting a number of men
and women to execute a series of rapid tapping movements with
the finger on a Marey’s tambour connected with a recording-
drum. It is found that the movements become retarded and
irregular sooner in women than in men.
Jastrow has observed some interesting sexual differences in the
association of ideas. Experimenting with University students
he got each of them to write down a word suggested by another
word which he displayed on a blackboard before them. This
process was repeated with several other words, and from the
results he concluded that “‘ masculine preferences are probably
for associations by sound (as man-can), from whole to part (as
tree-leaf), from object to activity (as pen-write), from activity
to object (as write-pen) and perhaps by natural kind (as cat-
dog); while feminine preferences are for associations from part
to whole (as hand-arm), object to quality (as tree-green) and
quality to object (as blue-sky) ”’
Woman is more emotional and leads a more instinctive life
than man and this characteristic is nowhere better seen than in
sexual relationship. ‘“‘A woman loves with her whole soul.
To her, love is life; to a man, it is the joy of life.’ Woman is
altruistic, man is egoistic; and this difference, together with many
others which have been pointed out, is found to produce a marked
influence on the insanities from which the two sexes suffer.
These are a few general inductive conclusions; but it is obvious
to everybody who thinks about the matter for a single moment
that no two people in the world exactly resemble one another,
either physically or mentally. It used to be supposed that these
personal differences are mainly due to inheritance, and this
belief still holds, to a large extent, in respect of bodily conforma-
tion; but, chiefly as a result of psycho-analytic investigation,
the view is gradually gaining ground to-day respecting personal
dissimilarities of mental constitution that they are principally
dependent on diversity of experience during the present life-
history of individuals, especially during early childhood, when
the mind is developing and being formed. We cannot help
being differently constituted; every thought, word and action
throughout our lives is unconditionally determined by previous
individually diverse experience—plus, of course, the existing
circumstances of the moment.
As a matter of fact, psychologists are now pretty well agreed
as to the truth of this doctrine, and its importance cannot be
THE UNITY OF MENTATION dtl ty,
overestimated. It is manifest that educationists and parents
or their surrogates should ever keep it in view, that clergymen
cannot afford to disregard it, and that it has some relation to
every walk of life. Especially we shall find that certain mental
disorders and nervous symptoms are solely traceable to the
patient’s past experience of life, and it is probable that, in the
near future, psychology will play a very important role in deter-
mining the destinies of man.
THE UNITY OF MENTATION.
In the above analysis of mentation it has been found possible
to consider separately such part-processes as sensation, percep-
tion, ideation, conception, cognition, recognition, memory, judg-
ment, reasoning, emotion, action and so forth; but it remains
to be pointed out that all these processes are interdependent
and that each, considered by itself, is merely an abstraction.
As a matter of practical experience even the most primitive
sensation aroused under the strictest experimental conditions is
a perceived sensation, and therefore a perception; and it has
already been said that the perception of an object is but an
abstraction from the perception of space in general. Further,
it is a matter of practical experience that the complete percep-
tion of any given object implies its cognition or recognition. The
revival of a percept, the formation of an idea, implies an act of
memory, as also does the formation of a concept. Again, the
formation of the simplest judgment, true or false, implies an act
of memory whether it be reliable, erroneous or even unconscious.
In the case of voluntary action, some zdea of an action must be
aroused before such action can be performed. A percept or
idea must be experienced or perhaps a judgment formed ere an
emotion can be aroused. Lastly it must be remembered that
every psychical process has its accompanying emotional tone
and that a complete mental process includes a motor reaction
resulting from any of the above-mentioned factors.
We find then that all mental processes considered in the first
part of this volume are connected together indissolubly; and
this is no more than might be surmised when we reflect on the
enormous wealth of association fibres existing in the central
nervous system between and among the physical bases of all
these mental processes and on the wealth of mental associations
originating from temporal or spatial contiguities of previously
experienced incidents and situations.
PART IL. |
PSYCHOLOGY OF THE INSANE.
Chr heels
DISORDERS OF SENSATION.
HAVING considered the way in which the nervous system sub-
serves the mental functions of a normal individual, it now
becomes our duty to consider in what way these functions are
disordered in cases of mental disease. In doing so the several
mental processes will be considered in the same order as in
Part li:
Among the insane, sensation may be altered in one of three
ways: there may be anesthesia, hyperesthesia or parzesthesia.
Nearly all the senses may be thus affected and there is a vast
field for research in this department of psychiatry.
Cutaneous Analgesia.—The several cutaneous senses may be
considered together since they are often simultaneously and
more or less coextensively affected; nevertheless, owing to the
difficulty of examining the insane, the best criterion of insensi-
bility is their response. to the prick of a pin, apart from the fact
that analgesia is much more common and usually more extensive.
Cutaneous analgesia occurs most commonly in stuporose and
confusional states. It is found in hysteria, the stadium de-
bilitatis of acute mania, in katatonia, exhaustion psychoses,
in alcoholic and epileptic confusion and in many cases of ad-
vanced dementia. When most extensive the whole surface is
anesthetic with the exception of a small area in the neighbour-
hood of the groins and the soles of the feet. The unaffected
areas commonly resemble bathing-drawers and sandals or, when
the anzesthesia is less extensive, knickerbockers and boots. In
the latter case there is commonly a sensitive area in the middle
of the face. Cases of less severity present analgesia of the legs,
arms (or forearms) and hands only. This analgesia in its smallest
extent, as found in some cases of dementia, involves only a few
small areas of skin on the backs of the proximal phalanges of the
118
119
ANALGESIA IN THE INSANE
Fic. 21.— EXAMPLES OF ANALGESIA IN
THE INSANE.
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occurring during t
longed attack of me
I20 MIND AND ITS DISORDERS
fingers. In a few patients exhibiting extensive anesthesia of
this kind, evidence of loss of muscular or articular sensation is
shown by their inability to pick up a pin.
As already stated this loss of sensation is most conveniently
investigated as analgesia by noting the response of the patient
to a pin-prick in various parts of the skin. Most patients with
this anesthesia are stuporose and confused and therefore unable
to make reliable statements about their symptoms, but in a few
it is possible to determine that loss of sensation to touch and
temperature exists more or less coextensively with analgesia.
It may be taken as a working rule that there is no analgesia of
this nature in a patient who retains sensation on the back of the
fingers. Some of these patients have diminution of deep sensi-
bility to pain, inasmuch as they exhibit a raised threshold to
Cattell’s algometer.
I am unable to furnish any explanation of the distribution of
analgesia in confusional states; but one cannot escape the obser-
vation that sensation in the genital area is preserved to the
last, as if to ensure the possibility of reproduction of the species,
even though this might be of a degenerate type. Another
observation worth noting is that the analgesia of sleep has this
same distribution.
On account of the fact that acute maniacs on the coldest day
in winter will strip, run into the open ward when covered only
with a thin cotton nightdress and open all the windows, it has
been inferred by some authors that they are insensitive to cold.
This inference is unjustified because it is impossible to detect
any loss of the cold-sense on careful examination of maniacal
patients during the acute stage. The tendency of acute maniacs
to strip is to be explained by their general hyperzsthesia and
their actions are but an expression of general motor restlessness.
Doubtless the particular form which this restlessness assumes
may have some deeper unconscious symbolic meaning. For
example, opening the windows on a cold day might symbolize
a desire to cool their passion; but such matters will be discussed
later.
Diminution of the visual sense occurs in some patients. Those
with the peripheral anzesthesia above described frequently have
contraction of their visual fields, directly proportionate in amount
to the extent of the cutaneous anesthesia. From the fact that
they will stare at the sun without apparently suffering any
inconvenience it is supposed that retinal sensation is diminished
in some dements, idiots and criminals; but this retinal anzsthesia
DISORDERS OF SENSATION I2I
must not be accepted as a fact until it has been experimentally
demonstrated that such patients are unable to detect minimal
visual stimuli which are visible to a normal individual. The
apprehension of colour remains apparently undisturbed in acute
cases of insanity, but in chronic cortical atrophy and in exhaus-
tion disorders (accompanied by imperception) there is failure of
discrimination among the unsaturated colours and among shades
intermediate in the spectrum between the primary colours. This
is especially the case with greens and blues.
The sense of hearing, as tested by the distance from the ear at
which the tick of a watch may be heard, is deficient in dementia
and in general paralysis. In the latter this symptom is occa-
sionally observed in the early stages, the friends of the patient
volunteering deafness as one of his symptoms on giving a history
of the case; but perhaps they mistake auditory imperception for
deafness. Many senile cases of melancholia and in a less degree
arteriopathic cases are unable to hear tones of very high pitch
such as are obtainable from a Galton’s whistle; this may be due
to senile sclerosis of the tympanum. Deafness is occasionally
the cause of mental disorder as in certain cases of deaf-mutism;
'it favours the onset of auditory hallucinations and even in the
sane is apt to give rise to the suspicion that others, taking ad-
vantage of the patient’s infirmity, are talking about them. The
deaf are thus rather predisposed to insanity.
The senses of taste and smell are diminished in dementia,
general paralysis and some confusional cases. General paralytics
usually take a lot of salt, and general observation has led me
to the conclusion that a person’s desire for salt varies inversely
with his intellectual capacity. It has been stated that there is
also loss of taste and smell in anergic stupor; the statement
is probably true, but obviously difficult to ascertain. Some
melancholiacs cannot appreciate flavours.
The genital sense is usually diminished in melancholia, epilepsy,
senile dementia and, after the initial stage, in general paralysis.
It is completely absent in some cases of neurasthenia.
The only visceral sensations whose disorder demands special
notice are those associated with the alimentary canal. The
appetite is lost in a very large number of the acute insanities;
this 1s so marked a symptom in melancholia that in many cases
there is absolute loathing of food. In katatoniac excitement
also, loss of appetite and consequent refusal of food are the rule;
these symptoms are but occasional incidents in other forms of
excitement. Loss of the sense of distension of the rectum is not
I22 MIND AND ITS DISORDERS
an infrequent occurrence, especially in melancholia and in the
tabetic form of general paralysis. In the latter case it is a
symptom of the tabes, not of the general paralysis; in the former
it may be due to apathy. This symptom is not to be confounded
with loss of the instinct of cleanliness, such as occurs among
advanced dements and other degraded patients. The condition
here referred to may be instanced by quoting the case of a melan-
choliac musician who, when his mental symptoms had apparently
passed off, would sit at the piano and play the instrument bril-
liantly until he felt that he had unconsciously evacuated his
rectum during the performance. He completely recovered from
his attack.
Similarly the sense of bladder distension may be absent in
some Cases.
Hyperesthesia of the various senses is difficult to determine.
Most observers are agreed that the symptoms of acute mania
justify the conclusion that all the senses are abnormally keen
in that condition. Hyperacuity of hearing is undoubtedly
common among maniacal patients; they can often hear a
whispered conversation at a distance of ten or fifteen yards. In
cases of neurasthenia and hysteria it is common for many of the
senses to be exalted; and melancholiacs are peculiarly sensitive
to noise.
The genital sense has been supposed to be hyperesthetic in
the early stages of general paralysis on account of the increase
of the sexual instinct. It is found on inquiry, however, that
there is no increase of the genital sense proper; the desire for
sexual intercourse is undoubtedly increased in general paralysis,
but the patient is frequently unable to complete the act and he
is as likely as not to go to sleep in the middle of it. In cases
of extreme peripheral analgesia the pelvic area, being the only
sensitive part of the surface, dominates the consciousness of the
patient and he is apt to commit indecent acts, especially to
masturbate. It would be erroneous to conclude that in these
cases there is tvue hyperzesthesia of the external genitals, since
the rest of the cutaneous surface is anesthetic; there is relative
hypereesthesia.
Increase of the appetite for food must be distinguished from
increase of the eating instinct. The general paralytic and the
chronic dement in some stages eat enormously, not so much
because they are hungry as because they are greedy. Some
maniacs eat voraciously because of their enormous appetite; and
there is one disorder in which increase of the appetite for food
DISORDERS OF SENSATION 23
is one of the most marked symptoms, viz., hypochondriacal
paranoia. Hypochondriacs (not hypochondriacal melancholiacs)
are always hungry.
Pareesthesize of the various senses are of frequent occurrence
among the insane; they are of the nature of simple illusions or
hallucinations and are therefore considered under these headings.
Erroneous localization is a symptom which frequently occurs
in cases due to coarse lesions of the cerebral cortex and in some
lesions of the spinal cord; but it occurs very seldom in functional
disorders. In my practice I have met with only one such case;
the patient was suffering from epileptic confusion and extensive
anesthesia, sensation being retained in small patches in the
groins and on the soles of the feet only; there was also contraction
of the visual fields. The interesting point about this patient was
that, in the areas which retained sensation, a pin-prick stimulus
was invariably referred to the corresponding spot on the opposite
side (allocheiria).
Whether the duration of sensations in the insane differs from
that of the sensations of the healthy has not been investigated.
Hysterical disturbances of sensation, such as local anzsthesias,
| hypereesthesias, pains, blindness and deafness, are of purely
psychical origin, being invariably a compromise between an
unconscious wish and repressing forces.
Examples were common enough during the War and were
diagnosed as “shell-shock’’. One type will suffice. The
soldier's unconscious wish was to see the Germans blown to
atoms; consciously he had no desire to see such a horrible
spectacle. When, therefore, he actually saw arms and legs
hurtled through the air he became blind, thus satisfying both
conditions. The unconscious was excused from seeing its wish
fulfilled, while the conscious was spared the pain of observing
repeated mutilations. Of course, quite a small proportion of
our millions of soldiers at the front suffered in this way, although
they were all exposed to the same conditions. This was due to.
the fact that there were deeper-lying personal factors in the
causation of these cases of hysterical blindness and of all similar
conditions, the nature of which will be discussed in subsequent
chapters.
CPNVE DE RSE
DISORDERS OF PERCEPTION.
THERE are three disorders of perception, viz., imperception
(including “‘ inertia of ideation ’’), hallucination and illusion. An
example of each will suffice to explain the meanings of these
terms. Let us start at the beginning. When a cigar lies on
the table before me and I see it and know that it is a cigar, the
process is one of perception; when there is nothing on the table
and I think of some cigar lying there, the process is one of idea-
tion; when there is a pencil lying there and I look at it and see,
not a pencil, but a cigar, the process is one of illusion; when there
is nothing on the table and I see a cigar lying there, I experience
an hallucination and lastly, if a cigar lies on the table, and I see
it but cannot tell what it is, I am suffering from imperception.
IMPERCEPTION.
)
Of late years this symptom has also been called “ agnosia ’’.
Patients suffering from imperception or agnosia are able to see,
hear, feel, taste and smell objects in their environment; but
they are unable, in spite of extended previous experience of such
objects, to place ideational content in the sensations aroused by
them.
The student is already familiar with such a state of affairs in
the domain of word-perception. Patients suffering from word-
blindness can see the printed page, but they cannot read it: the
words convey no meaning. If you address a patient suffering
from word-deafness, he hears you, but he cannot understand
what you are saying; you might as well address him in ancient
Greek. Here we have to deal with verbal imperception or verbal
agnosia. With these special forms of imperception we shall deal
in a later section; we are now speaking of imperception, not of
verbal symbols of objects, but of the objects themselves.
If a patient is given a bottle of oil of cloves to smell and he
tells you that he can smell it, that the odour is familiar, but
that he cannot tell what it is, he is suffering from olfactory
124
DISORDERS OF PERCEPTION I25
imperception. If you give him syrup to taste and he tells you
that he can taste it but cannot tell what sort of a taste it is, that
is gustatory imperception. If you show him a button-hook and
he cannot tell what it is, you have a case of visual imperception.
If you jingle a handful of coins behind his head and he says that
you are shaking a box of pills, he is afflicted with auditory
imperception. If you place a pair of scissors in his hand and
get him to feel them without looking at them and he says that
the object is a key, this would be tactile imperception, some-
times incorrectly called “ astereognosis ’’.
It must be left to the physician’s own resources to provide
himself with convenient tests for imperception. Inasmuch as
there are various degrees of imperception it is advisable for him
to carry in his pockets a few objects of unusual construction such
as a fancy match-box, a pencil-case and a knife with some un-
common implements in it. I have a small metal paper-knife
with a good-sized lens in the handle, which is usually somewhat
of a puzzle to arteriopaths. Such sounds as the tearing of paper
and the “‘siss”’ of a soda-water siphon in action are good tests
for auditory perception.
Pictures are useful tests for visual perception. For severe
cases I use one of Dean’s rag-books for children, called “‘ Baby’s
Object-Book’”’. It contains pictures of several common objects
with their names printed below; and a patient under examina-
tion is required to recognize the objects depicted therein, the
names being covered up. In order to detect slighter degrees of
imperception I use another picture-book for children, entitled
“ Proverbs Old Newly Told’”’. Each picture represents some
well-known proverb which the patient under examination is
required to recognize, the proverb itself being covered up. Of
course, only those pictures which tell their tale well should be
employed.
The name “‘ asymboly ”’ has been given to a form of impercep-
tion in which only the terminal stage of perception is wanting,
the stage in which a given object has to be referred to some
concept derived from the past experience of the individual. For
example, a man is shown a button-hook. He says: “This is
evidently a handle, and this is evidently a hook for holding
something.”” You reply: “‘ Quite right; what is the article ?”’
He replies: “‘ I don’t know; it is just a hook for holding some-
thing.”’ Again, you place a half-crown in his hand, without
allowing him to see it. He says: “‘ That is a metallic disc with
a thickened rim; the edge of it is rough, and there appears to
126 MIND AND ITS DISORDERS
be an embossed design on either side of the disc.’’ You reply
“Well, cannot you tell me what the article is ?”’ and he answers
“No, I can tell you nothing more about it.” You then tell him
to look at it, and he will probably say: “ Why, it’s a half-crown !”
—Tactile asymboly.
Agnostic perseveration or ideational inertia is a symptom
closely allied to imperception. Patients exhibiting this phe-
nomenon appear to be unable to get rid of an idea. A few
examples will serve to iulustrate the symptom. A man is shown
a pencil; he recognizes it and says it is a pencil. He is now
shown a match-box; he says it is a box for holding pencils. He
is next shown a paper-knife; he says it is a knife for sharpening
pencils. Take another case: A patient is shown a button-hook;
he recognizes it and says it is a button-hook for fastening boots
and shoes. He is now shown a knife; he says “ That is for
boots and shoes too!’’ He is next shown a silver match-box;
and he says “‘ That also is for boots and shoes ’”’, and so on.
Imperception, like other symptoms of mental disorder, exemph-
fies the principle that dissolution is a reversal of evolution.
There is a stage in the history of every child in which true percep-
tion of an object does not occur because the child has not yet
had experience of such objects. In dissolution the adult reverts
to this stage, his ability to take advantage of his previous experi-
ence having been obliterated by the ravages of disease. Idea-
tional inertia is also met with in childhood, generally about the
fourth or fifth year. Those who have had experience of ‘children
will think of many instances.
The Physical Basis of Imperception.—Imperception occurs in
association with disease of the cerebral arteries, in states of
exhaustion, in acute and chronic alcoholism and in other intoxi-
cations. Now these are exactly the conditions (intoxications
and interference with the blood-supply) which are known to
react most unfavourably upon the synapses.* We may there-
fore safely assume that the physical basis of imperception con-
sists of an increase of synaptic resistance within the association-
areas. Further evidence is given in later chapters. This same
increase of synaptic resistance will account for the phenomena
of ideational inertia.
Systematized Anzsthesia.—Although this disorder is a lack
of perception, it is in no way related to the imperception above
described. It occurs in some cases of hysteria, and patients
* Sherrington, “‘The Integrative Action of the Nervous System”’,
chap. i.
HALLUCINATIONS 127
manifesting the symptoms are unable to see, hear or feel a certain
person or object in the room, such person or object being usually
objectionable to the patient. Perception is otherwise normal,
and there is little mental confusion; it is merely that the said
person or object does not exist for the patient. The condition
is a simple exemplification of the general principle that all
neurotic and psychotic manifestations fulfil an unconscious
wish. The patient does not see or hear a person because he
does not wish to do so. Hurst, who belongs to another school
of thought, half realizes this factor when, in his Croonian Lec-
tures, he states that an hysterical patient does not see because
he does not look and does not hear because he does not listen.
This way of putting it is very near the truth.
HALLUCINATIONS AND ILLUSIONS.
An hallucination may be defined as a percept experienced in
the absence of any peripheral stimulus to cause such percept. In
illusion, peripheral stimulus is present, but not that stimulus which
would normally cause the particular percept experienced. For
example, if a person sees a ghost on a pitch-dark night or hears
bells ringing when all is silent, he is suffering from an hallucina-
tion; but if a will-o’-the-wisp appears to him as a ghost or if he
mistakes the chirp of a cricket for the sound of church bells, he
is suffering from an illusion. It must be distinctly understood
that the hallucinated person does not think he sees a ghost, he
does see a ghost; he does not think he hears bells, he does hear
bells.
Hallucinations are classified according to the sense-modality
in which they are experienced; thus there are hallucinations of
vision, hearing, smell and taste. There are also hallucinations
of touch, pain, and temperature, sexual hallucinations and
psycho-motor hallucinations of movement.
These perversions of perception may occur in the sane as well
as the insane. They are familiar to all of us in dreams and
in the hypnagogic state (state between waking and sleeping) ;
and they are liable to occur in association with the pain of
visceral disease. In the sane visual hallucinations are more
common than auditory; in the insane the reverse is the case.
Auditory hallucinations are more lable to occur in the insanities
of later life, visual in those of early life.
Hallucinations are either simple or complex, the complex being
mostly auditory or visual. To the class of simple hallucinations
belong vague shadows or flashes of light (photopsia), buzzing in
128 MIND AND ITS DISORDERS
the ears and hallucinations of taste and smell. To the class of
simple illusions belong such pareesthesiz as the epigastric and
abdominal sensations described below, parageusia in which the
food tastes as filth, and “‘ secondary sensations ’’’. Some of these
simple sensations are of considerable assistance in helping us to
understand the nature of hallucination and therefore require
careful consideration.
About 27 per cent. of the insane suffer at some time or other
from the “ epigastric sensation ’’ or from some allied sensation 1n
the neighbourhood of the abdomen or lower part of the chest.
This sensation is usually described as a sinking feeling but it
may be a feeling of fulness or even of pain. In its commonest
form it is experienced by the healthy on the receipt of bad news;
and it was owing to the frequent occurrence of such sensations
that the ancients regarded the heart, liver, spleen and intestines
as the seat of the passions. Even to-day we hear of a “ hard-
hearted ’’ man “ venting his spleen”’ against another, and the
same notion has given us the names “ melancholia ’’ (black bile)
and “‘ hypochondriasis ’’ (under the ribs). .
Epigastric and allied sensations most commonly arise in con-
fused and stuporose states. The epigastrium is the commonest
situation, but the umbilical region, the hypogastrium and the
external genitalia are frequent sites of similar sensations. Such
feelings are occasionally referred to the sternal region and it is
possible that such symptoms as “ globus hystericus ’’, “ neurotic
spine’, “hysterical hip’’ and “hysterical shoulder’’ may
sometimes be partially of the same nature.
A large number of cases presenting the above symptoms have
peripheral analgesia; and, conversely, all patients with well-
marked peripheral analgesia, who are capable of making any
reliable statement about the matter, when interrogated as to the
presence of an epigastric or allied sensation, answer in the affirma-
tive and it may be inferred that the sensation exists more or less
in all such patients. Further, although some patients have
the abdominal sensation without obvious peripheral analgesia
many of these tell us on examination that they do not feel a
pin-prick so well on the hand as on the trunk. It is therefore
justifiable to infer that patients having the abdominal sensa-
tion have more or less peripheral analgesia, in some cases to a
very slight degree, occasionally so slight as to elude detection.
One patient in Bethlem Hospital, whose symptoms suggested
such a view, was a neurasthenic who complained simultaneously
of a “‘ burning sensation’ in the hypogastrium and of “ loss of
THE EPIGASTRIC SENSATION I29
feeling ’’ in the legs, but I was unable to detect by crude methods
of examination any objective loss of sensation.
It is therefore to be concluded that the epigastric and allied
sensations arise when there is some loss of sensation in the
peripheral parts of the organism. In patients with analgesia of
this distribution, consciousness is mostly dependent on sensa-
tion derived from the abdomen, the more or less anesthetic parts
contributing little or nothing to the content of consciousness.
The abdomen and neighbouring parts thus “have greatness
thrust upon them ”’ and claim a large amount of attention; in
this way they become the seat of abnormal sensations.
The epigastric aura of epilepsy is a particular example of
epigastric sensations in general; it occurs when the patient is
losing consciousness, in other words, is losing sensation; and it
may be gathered that loss of sensation at the onset of an epileptic
fit sets in at the periphery, that the patient at this stage experi-
ences the epigastric aura and that the last event before the
patient falls is loss of sensation in the abdomen. Dr. Collins,
when superintendent of the L.C.C. Epileptic Colony, told me
that he could confirm this hypothesis, since he had discovered
peripheral anzsthesia in an epileptic during a prolonged aura.
Abdominal discomfort is also liable to arise in certain anxiety
states, especially in the anxiety neurosis and anxiety hysteria.
The pathology of this condition will be described Jater. For the
present it is to be noted that it is quite different from that of
the sensations above described.
Syneesthesiz or secondary sensations are those which accom-
pany sensations of another modality; for example, some people
experience with every auditory sensation an accompanying visual
sensation: the tone G is perhaps associated with the colour red
or the tone D with blue. Similarly sensations of colour may
accompany perceptions of taste, smell, touch, pain, heat or cold:
they are called “‘ photisms’’. With some people certain words
are accompanied by a sense of colour, varying with different
words (verbochromia). Again, there are secondary auditory
sensations called “‘ phonisms ’’, secondary taste sensations called
“ sustatisms ’’, secondary smell sensations called “ olfactisms ”’
and so on. These secondary sensations are here mentioned
because they throw light on the nature of hallucinations and
illusions by demonstrating that, at least in some people, the
visual centre may be stimulated by way of association-fibres
from the auditory, gustatory, olfactory and other centres and,
vice versa, that each of these centres may be stimulated by way
9
I30 MIND AND ITS DISORDERS
of association-fibres from any other centre. Secondary sensa-
tions are not especially associated with insanity. The nearest
approach to them encountered among the insane occurs in some
cases of simple melancholia. Some of these patients say that an
object, usually white or black, will appear, for example, green for
a few seconds. This phenomenon, probably due to some un-
conscious symbolic meaning of the colour green for that particular
patient, would be classed as a simple illusion.
Complex hallucinations of hearing are usually “‘ voices ’’, some-
times a babble of voices so that the patient is unable to distin-
guish what is said, sometimes a single voice making taunting
or other offensive remarks; occasionally there is even greater
complexity, as in the case of a patient who used to hear lectures
an hour long on Chinese literature, a subject of which he knew
nothing. It must not be supposed that these “‘ voices ”’ are in-
distinct and muttering; on the contrary, they are usually dis-
tinct and often very loud, so loud indeed that I have met patients
to whom it was necessary to shout in order to be heard above
the voices. In some cases these assume a tone of command;
such hallucinations are particularly dangerous since the patient
is apt to obey any hallucinatory suggestion to commit suicide or
homicide. In some cases there are two voices, one persecuting
the patient and the other taking his part; it is said that such a
condition points invariably to chronicity.
Other complex hallucinations of hearing are church bells or
music, sometimes of an orchestra in which the various instru-
ments can be clearly distinguished.
The apparent source of an auditory hallucination varies in
different patients: in decreasing order of frequency it is (I) over-
head, (2) under the floor, (3) on the same level as the patient’s
head. This order of frequency has obvious relationship to the
facts mentioned on p. 41.
The role of the “ unity of ideation ’’ in determining the apparent
source of an hallucination of hearing is dealt with later.
It has been said that, when hallucinations of hearing are
constantly referred to one side, the symptom is indicative of
coarse brain disease; this is not in accordance with general
experience. In cases of unilateral deafness from any cause
auditory hallucinations are liable to occur on the deaf side only,
but a few cases are recorded in which the hallucinations were on
the side opposite to the deafness. Apart from such patients the
affected side is usually the left.and the patients thus afflicted
commonly show hysterical symptoms, especially comparative
COMPLEX HALLUCINATIONS I3I
hemi-anesthesia of the right side. These conclusions are derived
entirely from observations made on right-handed patients. |
The deaf, but not the congenitally deaf, are especially liable
to hallucinations of hearing; it is said that Beethoven after he
became deaf heard in hallucination (or was it in ideation ?)
many of his earlier compositions.
Except in certain toxic cases, auditory hallucinations are, as
a rule, of evil prognostic significance; the exceptions to this rule
may sometimes be recognized by getting the patient to ascertain
whether he can still hear the sounds when his ears are stopped.
In the majority of cases they are no longer heard; but if they
still persist, the prognosis is more favourable since the patient
either believes or may be reasoned into the belief that the sounds
are hallucinatory. The result is obviously one of expectancy on
the part of the patient since the question whether he will or
will not hear the sounds with his ears stopped depends on the
depth of his belief in their reality; and the physician has already
done much toward the relief of his patient if he has convinced
him of the hallucinatory nature of the sounds he hears; he has
given him considerable insight into the nature of the malady.
This can occasionally, though rarely, be done by a suggestion to
the patient that, when he tries the experiment, he will hear the
sounds with his ears stopped.
Complex hallucinations of vision usually take the form of
faces; but in some patients they attain the most extraordinary
complexity. The late Dr. C. E. Beevor once told the author
of an epileptic whose aura consisted of the following visual
hallucination: Thirteen men stood before him, the first turned
and walked away, the second turned and walked away, the third
did the same, and so on until the last man hit the patient, and
he had a fit.
Visions may be pleasant or unpleasant. In some exhaustion
cases they are so pleasing that the patients like to keep their
eyes closed in order to enjoy to the full the beautiful scenes of
their phantasy, while in delirium tremens the patient is terrorized
by the horrible beasts he sees around him.
Sensations of light are experienced by normal individuals when
pressure is made upon the eye or after it has been struck. Such
sensations, which are known as “ phosphenes ”’, are due to direct
stimulation of the retina. Now in delirium tremens and, very
rarely, in some other conditions phosphenes are liable to appear
to the patient as pictures. Under such circumstances these
apparitions are usually spoken of as hallucinations; it is really
132 MIND AND ITS DISORDERS
more correct to call them illusions. They are easily induced by
light pressure on the closed eyelids of such patients and the
figures in such apparitions are usually in movement.
Moving objects in hallucination usually pass from left to right
or make their appearance to the left of the patient, advance and
disappear in the distance. This is the rule for right-handed
patients; in left-handed patients the movement is usually from
right to left. Right and left have a deeper significance for the
unconscious than for the conscious mind. They mean more than
one side and the other side of the body; the left is the weak and
awkward side: hence right and left may symbolize right and
wrong in various senses in different patients.
Hallucinations of vision may occur in the blind; they may
also occur in a single blind eye or even in a hemianopic field.
In the last case they are usually of a simple variety (lights).
Visual hallucinations are usually black, white and grey like
shaded drawings, especially in the more chronic forms of in-
sanity; coloured visions more frequently occur in the acute forms
(exhaustion psychoses).
Tests of prognostic significance, similar to that mentioned in
the case of auditory hallucinations, may be applied to visual.
The patient is directed to close his eyes when he has a vision;
if it disappears, the prognosis is less favourable than if it remains.
Hallucinations are never doubled by pressure upon one eyeball,
because such doubling of objects is not a sufficiently common
everyday experience to form part of a patient’s ideational equip-
ment. Hypothetically, if an hallucination were thus doubled
the prognosis would be hopeless.
Hallucinations of both vision and hearing are most frequent
at night when all is dark and quiet.
Hallucinations of smell may be pleasant or unpleasant. If
pleasant the odour is compared to that of flowers, fruits or
artificial scents; if unpleasant—and this is more common—it is
compared to the odour of feces, rotting corpses or something
burning.
Sir George Savage has stated that there is some relationship
between hallucinations of smell and disorders of the sexual
organs and function. With this the author is disposed to
agree, although the statement has not been allowed to pass
unchallenged.
Dr. Hughlings Jackson pointed out that the olfactory aura
of epilepsy is frequently associated with a ‘‘ dreamy sensation ’’,
It is probable that many hallueinations of taste are dependent
OTHER HALLUCINATIONS 133
on a dirty condition of the patient’s mouth and should there-
fore be regarded as illusions. They are almost invariably un-
pleasant and may give rise to ideas of poison.
Hallucinations of pain affecting the cutaneous senses occur
most frequently in some delusional forms of insanity, but not in
paranoia. Asarule, they are referred to the neighbourhood of the
abdomen and are described as electricity, magnetism, hypnotism
or some other form of unseen agency. Unconscious homo-
sexuality and anal erotism cause some patients to complain of
painful prods, pricks, stabs, shocks or darts, almost invariably
in the back (the disguised fulfilment of unconscious wishes);
but occasionally their unusual character may cause a patient to
coin a new word (neologism); he is ‘“‘ spreethed’’, ‘‘ spored”’,
“ cheefened’’’, “‘torched”’, “‘ petered in a hodge-podge”’ or
otherwise tortured by a “ teleform switch-battery confederacy
of blacklegs ”’.
Pain and other sensations sometimes occur as an hysterical
symptom. In such a case the sensations are usually more per-
sistent and the patient does not misinterpret their meaning
so grossly as the patients above cited, although the psychical
mechanism responsible for the hallucinations may be very
similar.
Hallucinations of warmth commonly extend all over the
surface of the body. They are common in melancholiacs and in
cases of paralysis agitans; many of these patients protest that
they feel quite warm when they are blue with cold. It is true
that many melancholiacs make such protests in order to avoid
the association with other patients round the fire, but there is
no doubt that in many cases the statements are perfectly true.
With other patients, again, the hallucination amounts to a feeling
of actual heat causing them to believe that an unseen fire is
raging around them.
Hallucinations of cold are rare; they may occur locally or
generally. In some cases a feeling of warmth is “shot over ”’
the patient and this is succeeded by a feeling of cold.
True tactile hallucinations are occasionally, but rarely, met
with. Their most usual form is perhaps the feeling that insects
are crawling over or under the skin; but it is possible that tactile
hallucinations are frequently overlooked, since patients would
not complain of them unless they were unpleasant. They are
possibly sometimes an element in the feeling of moisture, dryness
or dirtiness occasionally complained of by patients, the other
element being a sensation of cold or warmth. The occurrence
Loa MIND AND ITS DISORDERS
of these hallucinations of moisture has given rise in the Italian
school to the notion that there exists a distinct “‘ hygric ’’ sense
and they have been called “ hygric ’’ hallucinations. One writer
goes so far as to localize in the hippocampal gyrus a special
centre for sensations of moisture. Although no “ hygric’”’ sense
has ever been demonstrated, the feeling of moisture or wet-_
ness is a matter of common experience. It is a percept on a
higher plane than sensation; so are the feelings of dryness or
dirtiness.
The feeling, of which some patients complain, that there is
somebody behind them and perhaps looking over their shoulder,
might possibly be classed as a tactile hallucination.
The “‘ abdominal sensation ’’ and its congeners are sometimes
definitely tactile, but they are usually referred to the cesophagus,
stomach or intestines. Such sensations are then called “ visceral
hallucinations ”’ (q.v.). |
Sexual hallucinations are frequently met with, not merely
cutaneous sensations in the neighbourhood of the external geni-
alia, but specific sexual sensations accompanied by orgasm.
In women these apparently lay a foundation for delusions of
rape, but probably the more correct view is that the delusions
and the hallucinations are parallel symptoms, both of which
gratify an unconscious desire. |
Perhaps the most interesting of all hallucinations are the
psycho-motor. These consist of a feeling of movement of some
part without any movement actually taking place. Most
commonly this feeling of movement is in the mouth, the patient
feeling that he is saying words under compulsion. Patients
often complain most bitterly that obscene and blasphemous
words are thus forced, as it were, into their mouths, words which
they would be the very last people to use in their normal state
of health and of which they have an utter abhorrence. Such
hallucinations may induce the patient to believe that she (for
these notions are more common in women) thinks aloud or that
people are able to read her thoughts. Psycho-motor hallucina-
tions may also be referred to other parts of the body. For
example, one patient used to have the feeling that her arm had
darted up and struck a nurse and she always had to be reassured
that nothing of the kind had happened. Another used to feel
her hand pass to her head and pluck a hair, although she could
see her hand lying by her side. Another would complain that
she was made to breathe too quickly or too deeply, her respira-
tion being quite normal.
OTHER HALLUCINATIONS 135
This last is one of the forms of the so-called “ respiratory
hallucination ’’. Another feeling which some writers have de-
scribed as a “‘ respiratory hallucination ”’ is a complaint of some
melancholiacs that they have “no breath’’. The nature of this
sensation will be more fully comprehended when the general
principles of melancholia have been studied.
Hallucinations of the static sense sometimes occur. The
author has notes of only two such cases; both complained of
feeling upside down and falling. One was suffering from acute
confusional insanity and made a very fair recovery; the other
was a Jewess suffering from katatoniac stupor who did not
recover. In neither case was it possible to ascertain whether
the sensation was that of falling head first. However, we learn
from psycho-analytical experience that “ falling’? commonly
symbolizes “‘ falling’’ in a moralsense. The vertigo experienced
by patients suffering from labyrinthine disease or from lesions of
the cerebellum is scarcely to be classed as a true hallucination.
We occasionally come across an hallucination of such a nature
that it is difficult to determine to which sense it should be assigned.
As an example may be quoted the case of a Bethlem patient
_ who felt the earth to be constantly heaving or trembling like a
jelly under his feet. We cannot be quite certain whether this
sensation is to be referred to the skin, muscles or joints.
In the acute stage of delirium tremens and, very rarely, in
some other mental disorders hallucinations may easily be sug-
gested to the patient. If you say to him “ Look at that great
spider crawling towards you ”’, he will see a spider and be terrified
by it; if you say “ Listen to the noise of the machinery ’’, he will
hear it and perhaps say that he hears the engines of torture; if
you say.“ Do you smell those flowers ?”’ he will reply in the
affirmative, and so on.
Hallucinations of some kind or other occur in about 70 per
cent. of the insane, hallucinations of hearing in about 50 per
cent. In about 30 per cent. of patients one sense only is affected
in this way, in 20 per cent. two senses are affected and in Io per
cent. three senses. A few patients suffer from hallucinations of
five, SIX or even more senses.
At the beginning of this study of hallucinations a distinction
was made between these and illusions; but it has already been
seen that it is not always an easy matter to decide whether a
given sense-perversion should be classed under one heading or
the other, especially in the domain of smell or taste. The same
difficulty may arise in those cases in which illusions arise as a
136 MIND AND ITS DISORDERS
result of an irritative lesion of some sensory nerve. The false
perception will be called an hallucination if a diagnosis of the
irritative lesion has not been made. In some hysterical cases
the site and nature of an hallucination may be determined by
an organic lesion. For example, in a recent case of anxiety.
hysteria due to an ungratified sexual passion the patient heard
various sounds possessing a sexual symbolism (guns, lighted
candles, bells etc.) in her left ear, from which she had had a
discharge since infancy. She had a mastoid operation, but this
did not cure the hallucinations. These are the cases which
Freud calls “ Fixation Hysteria ”’
It is a question whether the epigastric sensation should be
regarded as illusion, hallucination or even percept.
Apart from these cases, illusions of whose nature there is no
possible doubt are frequent in the insane. Many patients are
liable to mistake the identity of those about them. The doctor
is greeted as the patient’s father, brother or husband and the
matron as sister or mother. At Bethlem Hospital a former head
male attendant used to be constantly mistaken for His Majesty
King Edward VII., especially by exhausted patients, although
that official bore no extraordinary resemblance to our lamented
Sovereign.
It is convenient to adhere to this old classification of hallucina-
tions under the headings of the various sense-modalities to which
they are referred; but many of our examples demonstrate that
hallucination does not lie in the plane of sensation, but in that of
perceptual experience. To this matter we must return later.
The physical substratum of hallucinations and illusions will be
clear to the student who has grasped the fundamental principles
of normal perception and ideation.
Our studies in the first section of this manual taught us that
perception consists of two part-processes, a physical and a
psychical. The physical process in perception is the stimula-
tion of an association-centre (ideational centre) by the media-
tion of a corresponding end-organ, the psychical process being
the feeling that there is ‘something there’’, and ideational
content derived from experience is placed in the ‘“ something
there™’,
It is clear that, in hallucination and illusion, the psychical
process is identical with that of perception; the difference
between these processes is therefore to be sought in the physical
mechanism and there is no difficulty in discerning wherein this
difference lies.
PATHOLOGY OF HALLUCINATIONS LS,
For the sake of simplicity let us limit our considerations to
the domain of vision and, for example, let us take the process
of seeing an orange on the table. In perception an orange lies
on the table and I see it, in illusion a biscuit lies on the table
and I see an orange, in hallucination I see an orange when there
is nothing there.
Now by studying hallucination in the insane, the writer has
determined that there is a negative as well as a positive side to
the hallucination process. To keep to our example, the positive
side is that I see an orange, the negative side is that I do not
see the table in the neighbourhood of the orange. It is with the
utmost difficulty that patients with hallucinations of vision can
see objects in the neighbourhood of an hallucination image (in-
deed the effort to do so may dispel the hallucination) ; and, during
hallucinations of hearing, patients can hardly hear real sounds.
I have known several patients with whom auditory hallucinations
were unceasingly present and to whom it was necessary to shout
in order to make my voice heard. All of these patients recovered
and were not deaf when the hallucinations ceased. If, as in
some cases, the negative factor is wanting, the patient voluntarily
supplies it; exhausted maniacs frequently keep their eyes closed
in order to favour the formation of pleasant visions or keep their
hands over their ears in order to favour pleasant auditory
hallucinations.
The probable explanation of the negative factor is that the
neurons, which normally conduct sensations from the end-organ
to the cortex, are dissociated from one another, presumably by the
retraction of gemmules. The positive factor, that I see an orange
when there is nothing there, means that the ideational centre
behind the angular gyrus is stimulated by way of association-
fibres other than the occipito-angular bundle. That this is
possible is indicated by the existence of “‘ secondary sensations ”’.
The hallucinated state is also favoured by the absence of
sensations of other modalities than that affected. It is for this
reason that hallucinations are most frequent at night when small
stimuli by way of association-fibres do not pass unheeded, but
induce a physical state with which a correlative “ something-
there ’’ psychical process occurs. The absence of other stimuli
allows the affected sensory area to dominate consciousness, idea-
tional content is placed in the “‘ something-there ’’, and the result
is hallucination. This principle was illustrated by the case of
a lady who, during the delirium of typhoid fever, was afraid to
close her eyes at night because, when she did so, she heard in
138 MIND AND ITS DISORDERS
hallucination horrible sounds apparently proceeding from a dis-
cordant brass band; during the day the music was pleasant and
she would close her eyes in order to hear it. In this case visual
stimuli were sufficient to inhibit the auditory hallucination.
The two factors, diminution of sensation and disturbance of
association, upon which hallucination depends, vary inversely
in the several conditions in which it occurs. For example, in the
delirium of fever and in the motor excitement accompanying
some states of exhaustion there is little anesthesia and great
disturbance of association, whereas in cases of nitrous oxide or
chloroform inhalation there is marked anesthesia and little
disturbance of association.
Illusion differs from hallucination in that there is no peripheral
dissociation.
It will not have escaped the reader that the physical mechanism
of hallucination is precisely the same as that of ideation. The
psychical differences are that the hallucination image is vivid
while the ideational image is faint and that the ideational image
is accompanied by a sense of past direction in time (then-ness)
while the hallucination image is accompanied by a sense of the
present (now-ness).
The above theory of the nature of hallucinations receives
support from the fact that, under certain circumstances, mere
suggestion suffices to induce hallucinations. They may be so
induced in hypnotized persons and even, by means of the follow-
ing laboratory experiment, in normal individuals.
A blue bead, 14 inches long by # inch wide, is suspended against
a black background. This is shown to an observer, who walks
away from it along and to the end of a graduated line. He is
then told to approach the bead slowly and to mention directly
he sees it. This proceeding is repeated twenty times with each
observer. Every now and then the bead is withdrawn by a
concealed arrangement, but it sometimes continues to be seen
when it is not there (by about two-thirds of the observers). In
this experiment the feeling of ‘‘ now-ness’”’ is artificially aroused
in the observer, so that he does not realize that his percept
is a revived one and the result is that he projects a vivid
instead of a faint image; in other words, he has a true
hallucination.
Hallucination and illusion, then, are to be regarded as dis-
turbances of the normal processes of ideation and perception,
illusion being more nearly related to perception, and hallucina-
tion to ideation.
PSYCHOLOGY OF HALLUCINATIONS I39
Psychology of Hallucinations and Illusions.—The physiological
mechanism of hallucination and illusion above described is the
same for all patients, but we have so far taken no account of the
fact that the particular form which hallucinations and illusions
assume varies from patient to patient. ‘Nothing could remind
us more forcibly than this that every patient is a problem in
himself, having a personality and individuality of his own, and
that we have to study his individual psychology. /Unconscious
desires are more or less the same in everybody, but the particu-
lar form which an unconscious desire assumes in any given
individual depends upon his particular experience of the world;
_and hallucinations and illusions are nothing more than the ful-
filment of unconscious wishes, in much the same way as dreams
are—the only difference being that an insane person actually
lives his dream. In dementia preecox, for example, the halluci-
nations are the unconscious creation of a world in which the
patient wishes to live; in many cases hallucinations are merely
the crystallization of delusions; the terrifying hallucinations of
delirium tremens usually have a phallic signification; while
hysterical hallucinations are a compromise between conscious
‘and unconscious wishes. These various statements will be
better understood by the student after he has learned the pyscho-
logical characteristics of the several mental disorders.
Difficulty of Ideation.—On p. 43 we had occasion to remark
that a greater effort of attention is necessary to ideation than to
perception. Accordingly we find that ideation is difficult for
all patients suffering from defective power of voluntary atten-
tion. Melancholiacs, for example, often complain that they are
unable to picture (7.e., to visualize) their dearest friends and
relations. This is probably due to the fact that unconsciously
they do not wish to do so. Physically this symptom is due, as
we shall see later, to partial paralysis of volition and voluntary
attention. Difficulty of ideation occurs also in all cases of
imperception.
The ideational type of the insane is difficult of investigation
not only on account of their confused state of mind, but also
because they are mostly unpractised in psychological intro-
spection. The small number of satisfactory observations which
I have made in this direction do not warrant any conclusion
being drawn. The type appears to be as variable as in sane
people.
CHATTER SITL |
DISTURBANCES OF THE ASSOCIATION OF IDEAS.
THE association of ideas may be disturbed in one or more of
three different ways: it may be (1) retarded, (2) accelerated or
(3) there may be disorder of the normal ideational sequence.
(1) Retardation of the flow of ideas may result from
(a) partial paralysis of the cortical neurons, (6) destruction of
many of the cortical neurons, (c) incomplete development of
the cortical neurons or (d) more or less extensive peripheral
(cutaneous) anesthesia. |
(a) The cortical paralysis here referred to is that which occurs
in melancholia. The reasons for the belief that such paralysis
is the physical basis of melancholia are fully discussed under
that heading. It has been determined by means of the reaction
apparatus that association-time is increased in all states of
depression and it is a matter of everyday experience, not only
that melancholiacs are slow of thought, but also that physio-
logical melancholy is inimical to successful thought.
(b) Destruction of the cortical neurons occurs, or rather has
already occurred, in all forms of secondary dementia, especially
in that of general paralysis. In these cases retardation of
thought is a pronounced symptom. It also occurs in most cases
of organic insanity in which the destructive lesion is of wide
extent and in association with degeneration of the cerebral
arteries.
(c) Incomplete development of the cortical neurons in idiocy
and imbecility presents a clinical picture similar, so far as the
flow of thought is concerned, to that which is presented by their
subsequent destruction.
(d@) When, on account of cortical disturbance, a large area of
the surface of the organism becomes anesthetic, the process of
ideation lacks much of its normal stimulus, the ordinary stimuli
to thought being sensations derived from various parts of the
body, particularly from the organs of special sensation, including
the skin. Hence we find that, in states of exhaustion, confusion
and stupor associated with peripheral anesthesia, thought is
140
ACCELERATION OF THE FLOW OF IDEAS Tar
retarded to such an extent that it appears in many cases to be
completely arrested.
(2) Acceleration of the flow of ideas occurs in maniacal excite-
ment. Increased rapidity of association is to be inferred from
the speech of an acute maniac. When he is incoherent, the flow
of his ideas is so rapid that it is impossible for an observer to
trace any connection between them, but at times it becomes
possible to discern their association. One example will suffice:
the writer offered a cigarette to an acute maniac, who imme-
diately remarked, “‘ Tobacco, Virginia, Virgin Queen, Elizabeth,
my mother’’, as quickly as the words could be uttered. Such
rapidity of association is impossible in a sane man; it is known
as the * flight of ideas’. This tendency to rapid association in
such patients is by no means a persistent phenomenon; it easily
tires.
(3) Disorder of the normal sequence of ideas is characteristic of
all states of excitement and is dependent upon lack of attention.
It is perfectly true that the association of ideas in these morbid
states obeys the ordinary laws relating to the frequency, recency,
relative position and vividness of the associated idea; but
‘whereas, in a normal individual, irrelevant associations are
more or less inhibited by some interest in or attention to a goal-
idea, in maniacal states such interest or attention is wanting
and association becomes free and disordered from lack of in-
hibition.
It must not be supposed that patients with fixed delusions suffer from
disorder of the process of association so far as ideational sequence is con-
cerned. The judgments are erroneous for other reasons which will be
discussed in a subsequent chapter.
DISORDERS OF MEMORY.
Of disorders of memory there are three, respectively known
as amnesia or loss of memory, hypermnesia or excess of memory,
and paramnesia or falsification of memory.
Amnesia.—There are two varieties of amnesia—(1) inability
to retain new mental impressions (anterograde amnesia) and
(2) inability to recall former mental impressions (retrograde
amnesia). Anterograde amnesia may occur by itself, but retro-
grade amnesia is always accompanied by anterograde. The
former variety occurs to a slight degree in severe cases of
melancholia, to a greater degree in the mental degeneration
of senility and it is most marked in cases of anergic stupor
I42 MIND AND ITS DISORDERS
and, in a way, in post-epileptic states and so-called masked
epilepsy.
In seeking the cause of any disturbance of memory it is neces-
sary to bear in mind the results obtained from experiments
with the memory apparatus. It will be remembered that the.
tendency of an idea to be subsequently recalled depends on its
vividness, on the amount of attention paid to it, on its frequency
of occurrence and on the prominence of its temporal and spatial
position in any given series of ideas.
Now in the several conditions in which there is inability to
retain new mental impressions it is seen on examination that
the cause of the disorder of memory varies. The disorder is
always slight in melancholia; but, when it occurs, it is entirely
dependent on lack of attention to mental presentations. It is
possible that this factor also plays a part in the causation of
the memory disturbance characteristic of old age; but here there
is another factor which must be borne in mind, viz., that with
an old man a new idea stands out less prominently among his
hundreds of thousands of previous ideas than with a young man
whose ideas have been much less numerous. The hypothesis has
been advanced that the cortex “loses its plasticity ’’ in old age.
This phrase I take to mean that the cortical neurons work stiffly
and are inelastic in their action, like the old man himself. It
may be so.
In anergic stupor and in exhaustion states the chief factor in
the causation of memory disturbance is more or less extensive
peripheral anesthesia, which destroys the vividness of all per-
cepts. In this condition attention also is wanting and the
result is that such patients completely lose the memory of the
greater part of their illness.
In states of post-epileptic automatism and of masked epilepsy,
patients are liable to perform most complex actions full of inci-
dent and yet be unable subsequently to remember anything
about them. I do not know of any record of a systematic
examination of patients in these conditions, but circumstantial
evidence goes to show that there is neither loss of sensation nor
lack of attention. All that we are able to say is that the con-
tent of post-epileptic consciousness is dissociated, at its onset
and its close, from that of the normal consciousness of the
afflicted patient. Dissociation from the previous mental con-
tent may easily be accounted for by the loss of consciousness
which is the essential part of an epileptic fit; but what exactly
happens when the patient returns to his normal condition it is at
AMNESIA 143
present impossible to say. We shall have to discuss the matter
more fully in connection with the splitting of consciousness.
For the moment let us be satisfied with the recognition that, in
accordance with the general psychological principle that every
mental symptom is the fulfilment of an unconscious wish,
although frequently in a disguised form, mental patients suffer
from amnesia of a given period because they wish to forget it.
The defective memory of imbeciles is mainly due to lack of
attention.
We now come to the discussion of those conditions in which
a patient is unable to recall previous mental impressions (retro-
grade amnesia). Such conditions occur during post-epileptic
states, in states of exhaustion (confusional insanity), in secondary
dementia of all kinds and in organic insanities.
The post-epileptic states have to be again mentioned in this
connection because account must be taken, not only of the fact
that incidents occurring in these states are subsequently for-
gotten, but also of the fact that during such states the patient
forgets all about his normal life. We are here dealing with a
variety of double personality, and it may be mentioned in this
' connection that there are also cases of double personality which
are certainly not epileptic. There are, also, post-epileptic states
in which loss of memory takes place in accordance with the “ law
of regression ”’ to be presently described. The progressive loss of
memory characteristic of dementia is invariably in accordance
with this law. Lastly, we must bear in mind that the normal
tendency to forget painful situations and incidents or, at least,
other situations and incidents which might remind us of them is
also present in the insane, and many of their amnesie, including
some of these above mentioned, are due to this normal mental
characteristic.
The law of regression of memory is but a special application
of the law of dissolution of the nervous system, that dissolution
takes place in the reverse order of evolution. The earliest
functions of the nervous system to be evolved are the least
complex, the least voluntary, the most instinctive, and these
ultimately become the most organized. The last functions
to be evolved, and therefore the least organized and most un-
stable, are the most complex, the most voluntary and the least
instinctive. Dissolution takes place in the reverse order, the
most complex and least instinctive functions being the most
likely and the first to become affected, and the least complex
and most instinctive are the least likely and the last to become
T44 MIND AND ITS DISORDERS
affected. This law is applicable to the evolution and dissolution
of memory. The memory of recent events goes first, that of
remote events last; and, in general, it is found that ideas are
forgotten before actions. In the domain of language dissolution
takes place in the following order: proper names, common
nouns, adjectives and verbs, and lastly interjections, this being
the reverse order to that in which these parts of speech are
acquired.
Occasionally a retrograde amnesia is only for events which
are recent in relation to a given time. This condition was ex-
emplified in a remarkable manner by a female patient, aged
fifty-six, who was admitted to Bethlem Hospital on November 28,
1896, on account of an attack of insanity following head injury.
On admission she was confused and used to nurse the pillow,
saying that it was her newly-born son. On December 7 she
said that this son was three weeks old, that the year was
“ eighteen-sixty-something ’’ and that her own age was thirty-
nine. When asked whether she remembered Queen Victoria’s
Jubilee she remembered some public rejoicings about the year
1850 (apparently the 1851 Exhibition). On December 9 she
said that she was aged forty-two and her son six years; on
December 21 that she was fifty and her son twenty; and on
January 3, 1897, when she had practically recovered, she stated
that she was fifty-six years old and her son twenty-six. This
was true. The possibility of the amnesia being the fulfilment of
an unconscious wish did not occur to me in those days.
In advanced dementia patients remember practically none of
the incidents of their later life, but even in this condition the
ordinary rules of memory hold good to some extent. For
example, any incident which makes a profound impression is
liable to be remembered. For this reason, if for no other, it is
not wise to promise even the most advanced dement that his
name will be placed on the next discharge-list, in the hope that
he will forget. Such a promise may make an impression too
profound to allow it to be forgotten.
The loss of memory in acute confusional insanity appears to
be more extensive in its range than in the above conditions.
In this state some patients forget even such thoroughly organized
ideas as their own name, much less can they tell their where-
abouts in space and time. The physiological explanation of
these amnesiz is as follows: in many of the above states, especi-
ally in anergic stupor, acute confusional insanity and advanced
dementia, there is loss of sensation, which is at times very con-
AMNESIA 145
siderable. This is dependent upon damage to the cortical
neurons (? synapses) and therefore to the ideational centres in
which memory images are revived. Such damage is temporary
in stupor and confusion, permanent in dementia.
It is found that, after recovery, all cases of epilepsy (masked
or otherwise) and of post-epileptic automatism, most cases of
anergic stupor and some of acute confusional insanity have
little or no remembrance of the attack. The same may be said
of many cases of head injury and sudden organic brain lesion.
Such events give rise to gaps in the patient’s memory, mental
scotomata or lacunz which have been called partial amnesiz. In
most of these conditions this is easily explained by the fact
that sensation, and therefore consciousness, is either abolished
oratavery lowebb. On the other hand no satisfactory explana-
tion has yet been offered for the loss of memory in post-epileptic
automatism or masked epilepsy. To say that dissociation of
the mental state takes place at its onset and close is, after all,
merely a restatement of the facts in more obscure terminology.
The condition appears to be rather a cramping of the memory
than a complete amnesia, for the patient can often perform
complicated feats which necessitate the retention of memory of
some sort, a kind of subconscious memory. Another circum-
stance for which no satisfactory explanation has yet been offered
is that, in many of these states, the patient loses memory of
events which happened immediately (twenty minutes or so)
before the cerebral shock occurred.
It will be observed that some of the phenomena described
under the heading of imperception may also be regarded as
instances of partial amnesia.
There are many experiments which may be made to determine
a patient’s memory for recent events. He may be asked to say
what time of day it is,* what day of the week, day of the month,
what month and what year. He may be asked what he had for
his last meal. Marie employs the following test: the patient
is given three pieces of paper of different sizes and is told, for
example, to fold the large piece into three and to put it under
his pillow, to fold the medium-sized piece into four and give it
to the nurse and to tear up the small piece and throw it out of
the window. Another ordeal devised by Marie is to tell the
patient to go and tap three times on the window-pane, to open
* Most healthy people can estimate the time of day to within a few
minutes, especially if they have seen a clock or met with some incident
jndicating the time within the past two hours.
10
40 MIND AND ITS DISORDERS
and close a given door, to return to his seat, make a military
salute and sit down. Such trials as these usually bring out any
defect of recent memory on the part of the patient.
As a test for the revival of memory-images a patient may
be asked to enumerate a dozen birds, animals or flowers. If
he fails to do so, his capability of reviving memory-images
is deficient; if he repeats himself, there is some loss of recent
memory.
The late Dr. Mercier drew attention to what he believed to
be another variety of loss of memory, which he called, paradoxi-
cally, ‘‘loss of memory for future events”. He referred to
patients who forget appointments, forget that they have to
write an urgent letter, to catch a train or to lock the safe before
leaving the office. Clinically it is important to recognize this
symptom, the forgetting of resolutions, because it is liable to
occur during the early stages of any form of mental disorder;
but psychologically it is nothing more than an exaggeration of
the normal function of forgetting (g.v. p. 50), the exaggeration
being due to the fact that the repressing forces are weakened
in all forms of mental disorder, and indeed in nearly every
disease, whether mental or physical. A resolution is for-
gotten because of an unconscious wish that it should not be
carried out.
Hypermnesia.—In many cases of mania, especially of chronic
mania, a condition is met with in which the patient has remark-
able exaltation of memory. He can tell with perfect accuracy
what happened to him or what he was doing at any given date
since the beginning of his illness; or he can instantly recall the
name of any person he has seen, perhaps only once, and that
years ago, but since the beginning of his illness. This pheno-
menon is doubtless related to the general hyperesthesia of these
patients. Stimuli of moderate intensity arouse in them more
vivid percepts than in normal people and are hence more liable
to attract their attention. :
Partial hypermnesia is frequently observed in cases of im-
becility. . In these cases there is no general hypermnesia, but
there is an exaltation of memory for ideas or incidents of a par-
ticular nature, which arouse their interest and attention. ° Other
ideas and incidents have no interest for them, and for these their
memory is exceedingly bad. Some havea remarkable memory
for dates. A patient at Prestwich Asylum could enumerate all
the occasions on which any given medical officer of the institution
had played tennis.
PARAMNESIA 147
Paramnesia.—We have already seen that an essential part of
any act of memory is the emotional tone of familiarity. Now
if this emotional tone should arise during an act of perception,
the total process is one of recognition; and should the feeling
arise during an act of ideation or conception, the total process
is one of memory. In the insane, and occasionally in the sane,
this mood of familiarity may arise without any justification; for
example, (a) the mood of familiarity may arise in entirely new
surroundings, with the result that the person so affected thinks
he has “been there before”’; he recognizes his surroundings:
(>) the mood arises in association with the idea, for example, of a
visit from a friend, with the result that the person remembers the
visit, which has not occurred. These abnormal psychic processes
are known as paramnesia. Curiously enough, the latter process,
which is the more complex of the two, has been called “ simple
paramnesia ’’ and the former has been called “‘ paramnesia by
identification ’’. Such nomenclature is confusing. The two pro-
cesses respectively should be spoken of as * illusions of recogni-
tion ” and “illusions of memory ’’. In thus naming them there is
no misuse of the word “illusion ’’; for paramnesia is practically
a misrepresentation which originates in sensations, sensations
derived from those muscular and arterial changes which underlie
the mood of familiarity.
Illusions of recognition and memory are liable to occur in any
form of insanity in which the emotions become dominant but
are most common in the variety of mental disorder usually
associated with multiple neuritis, the ‘‘ polyneuritic psychosis.”
CHAPTERS:
DISORDERS OF THE EMOTIONS.
In this section we have to consider morbid modifications of
the emotional reaction to percepts and ideas of situations and
incidents in the outside world. In the insane such emotional
reaction may be excessive or deficient, the cause of the excess
or defect differing in the various diseases with which we have
to deal.
Persistent states of depression and hilarity are common in
many forms of mental disorder, especially in maniacal-depressive
insanity, and it is better to defer their consideration until this
disease is discussed. Until recently no explanation was forth-
coming why general paralysis has such a remarkable tendency to
induce a persistent emotional state of happiness and exaltation.
In those conditions which are dependent upon progressive
deterioration of the nervous system, such as general paralysis,
alcoholic insanity and epileptic insanity, emotional reaction is
excessive, the most unimpressive word or gesture often sufficing
to induce an attack of weeping, laughter or anger. The same
may be said of maniacal excitement. Paranoiacs and patients
suffering from hallucinations are especially liable to outbursts of
anger and other forms of emotion. Imbecility, too, is a condition
in which excessive emotional reaction may be observed. We
have also to consider those patients who suffer from morbid fears.
Deficient emotional reaction, on the other hand, characterizes
confusional and stuporose states, myxcedema, cretinism, senility
and all extreme forms of secondary dementia.
EXCESS OF EMOTIONAL REACTION.
The doctrine is now well established that dissolution of the
nervous system takes place in reverse order to its evolution, and
it has been demonstrated that the last motor tract to develop
in the history of the vertebrate nervous system is the pyramidal
tract. It is in accordance with this doctrine that the first motor
tract to suffer in such progressive degenerations of the nervous
148
EMOTIONAL DEFECT I49
system as general paralysis, alcoholic insanity and epileptic
insanity is the pyramidal tract; and the consequence is that
in these diseases motor impulses tend more and more to be
transmitted by way of the more primitive motor tracts vid the
red nuclei.
Now these are the tracts which normally subserve the function
of emotional reaction and so it happens that patients suffering
from the above diseases react emotionally to unimpressive
stimuli whose main outlet is by way of emotion-arousing tracts,
the volitional tracts being unavailable.
In states of maniacal excitement the tendency to excessive
emotional reaction is dependent upon a different set of condi-
tions. In the chapter on maniacal-depressive insanity I shall
show reason for the belief that mania is a state in which the
neurons contain some irritating body or bodies; the neurons are
consequently in a permanent state of excitability. The result of
this constant state of tension of the neurons in maniacal states
is that minimal stimuli provoke nervous discharge and, in the
case of motor neurons, induce muscular contraction.
The application of this principle to the emotionality of maniacal
‘patients is as follows: a perceptual or ideational process occurs
in one of the association-areas of the cortex; all the neurons
in functional communication with this area, especially the cortico-
rubral neurons, are discharged; in other words, discharge over-
flows into the emotional regions of the nervous system.
The emotional outbursts of paranoiacs and of patients suffer-
ing from hallucinations may be looked upon as being due to
excessive perception, in contrast to those forms of diminution
of emotional reaction which are due to imperception (vide infra).
The laughing or weeping of a patient, who has just experienced
an illusion or hallucination, takes place because he has perceived
something (which is not there); he has suffered from excess of
perception.
Similarly paranoiacs suffer from excess of perception; their
association of ideas is excessive and they see hidden meanings in
the most trivial incidents, A passer-by in the street blows his
nose and the paranoiac perceives the handkerchief as the cloak of
a sneer or smile; the result is the emotional reaction we call anger.
The excessive emotional reaction characteristic of the imbecile
is to be accounted for as follows: The nervous system of the
imbecile and therefore his pyramidal system, which even in a
normal child is developed late, are incomplete in development.
Accordingly the pristine cortico-rubral system is uncontrolled,
I50 MIND AND ITS DISORDERS
the volitional pyramidal system being unavailable to take over
its usual share of the functions of the pristine system. It is
this uncontrolled action of the pristine motor system which
must be held responsible for the excessive emotional reaction of
the imbecile.
Morbid fears arise in quite another way. They are really
symptomatic of unconscious desires. When a person experiences
a desire which, for some reason or other, he does not wish to feel,
perhaps because he thinks it wrong or wicked, he represses it
into his unconscious, and it becomes replaced in consciousness by
its opposite, namely fear. He then suffers from morbid fear of
any situation which tends to remind him of his unconscious
aspiration, even symbolically. In some cases, on the other hand,
the fear is traceable to some situation, consciously forgotten but
remembered by the unconscious, to which the patient did not
react emotionally at the time; so that, as it would appear, there
is a certain amount of emotion (fear) floating about loose, so to
speak, which tends to attach itself to any situation resembling
the original, even remotely. Examples of both these mechanisms
will be given in due course.
DEFICIENCY OF THE EMOTIONAL REACTION.
If you tell a person a good joke, there are three possible
reasons for his not laughing at it: (1) He does not hear it, (2) he
does not “see”’ it or (3) he is preoccupied. Such are the three
causes of deficient emotional reaction among the insane.
In confused and stuporose states the patient suffers from anes-
thesia of characteristic distribution. In such cases perception
is deficient because sensations are not satisfactorily served up
to the ideational centres and emotional reaction is absent for the
same reason that a deaf man does not laugh when you tell him a
joke. It is also to be observed that in these patients there is a
further reason for the loss of emotional feeling in that the muscular
sense is defective; the patient would not fully experience an
emotional feeling, therefore, even if slight motor reaction should
occur.
Emotional defect may be due to partial or complete imper-
ception. This occurs to a greater or less extent in cases of
secondary dementia, arteriosclerosis, myxoedema, cretinism and
idiocy. In all these conditions there is corresponding deficiency
of emotional reaction, for the same reason that some people
cannot “ see’ a joke.
EMOTIONAL DEFECT i hei
In some cases of this kind emotional reaction occurs, but its
character is inappropriate to the occasion. For example, it
sometimes happens that an advanced dement laughs on being
told that a relative, once dear to him, is dead. Those familiar
with psycho-analysis will discern a further explanation of this
phenomenon.
Absence or deficiency of emotional reaction occurs in severe
cases of melancholia, not only of pleasurable, but also of painful
emotional reactions. Such patients experience no pleasure when
they think of their home, wife and family; they commonly tell
us that they have lost all affection for their friends; and when it
becomes our painful duty to inform a melancholiac of the death
of his nearest and dearest relative he commonly remarks “ I
don’t seem to feel it’.
The cause of this lack of emotional reaction is not far to seek.
As I shall point out in a subsequent chapter, the greater part
of the muscular system of melancholiacs is rigidly fixed owing
to partial paralysis of cortical neurons, and it is on this account
that the motor changes essential to emotional reaction cannot
take place.
Katatoniac stupor also is characterized by muscular rigidity.
This rigidity differs from that of melancholia in that it affects
the whole of the muscular system uniformly, whereas the rigidity
of melancholia affects mainly the musculature of the spinal
column and the large proximal joints. The practical point
is this: that in katatoniac stupor there is motor fixation as in
melancholia and it is on account of this fixation that there is
deficiency of emotional reaction.
Later we shall see reason for the belief that the deficiency of
emotional reaction in other forms of dementia preecox is apparent
rather than real and that the reaction is only repressed by these
patients.
The conclusions arrived at in this section may be summarized
as follows: Excess or defect of emotional reaction may be
dependent upon excess or defect of sensation or upon excess
or defect of perception. Excess of emotional reaction may also
depend upon an abnormal tendency of motor impulses to be
transmitted via the pristine emotion-arousing nervous system.
Defect of emotional reaction may further be due to fixation of
the emotion-arousing musculature.
CHAPTERS:
ABNORMALITIES OF ACTION (DISORDERS OF CONDUCT).
DISORDERS OF VOLITION.
THE insane are liable to perform all sorts of abnormal acts as the
result of insane delusions. Of such a nature are the setting of
traps in order to ensnare supposed persecutors, the barricading
of doors to obstruct the ingress of supposed enemies, the plugging
of keyholes to prevent poisonous gases being instilled into the
room, the wearing of concealed armour and the more ostenta-
tious wearing of fantastic dress, tinsel crowns and self-conferred
medals. I have known a patient, suffering from the delusions
that she was infectious, eat such refuse from her food as nut-
shells and fish-bones lest these should convey infection to another
person. All such voluntary acts are hable to degenerate in time
into automatic acts; they are then known as insane habits.
More important still are the drug habits (alcohol, morphia,
cocaine etc.), which will be considered in their proper place.
Paralysis of volition, 7.e., paralysis of the capacity of forming
a clear idea of a movement to be performed, is known as apraxia.
This is paralysis of the “ highest motor level”’ of Dr. Hughlings
Jackson, which is situated in the left prefrontal lobe, not paralysis
of the middle level whose cell-stations are in the Rolandic motor
areas. Apraxia consists of an inability to perform certain
actions, although the person suffering from it has no paralysis
of movement or sensation of the affected parts. Ifa patient be
told to raise his arm, to point at an object or to shut a book he
makes movements which are quite inappropriate. If he be
shown a candle, given a box of matches and told to light the
candle, he appears to have no idea of the movements required
for such an action.
There are two varieties of apraxia—agnostic and ideomotor.
Agnostic apraxia is dependent on imperception or agnosia (vide
p. 124). In this form the patient is unable to perform a given
action because he does not recognize the nature of the article
152
APRAXIA 153
which he is required to use for such an action. For example, a
man is shown a pencil but does not recognize it as a pencil; he
does not know what it is because his perception is defective. If
now he is told to write something with the pencil his movements
are confused; he makes no attempt to write, because he does not
grasp the fundamental idea that the article in his hand is an
implement for writing.
In the other form, ideomotor apraxia, to keep to the same
example, the patient knows that he holds a pencil in his hand
and knows what it is for; yet when he is told to use it he fumbles
with it and appears to have no idea of the movement of writing.
It is a good test for motor apraxia to get the patient to measure
some object with a tape-measure. In order to detect slighter
degrees of apraxia it is a useful test to get him to perform a
given action without all the articles required for such action.
For example, give him a button-hook and tell him to go through
the movement of fastening a button with it; in other words,
to pretend to fasten a button. The resulting movements in a
case of apraxia are nothing like the correct movements although
the patient may be able to button his own boots. Asa still more
'severe test he may be asked to show how he would count out
change (money), but without any coins; he will perhaps go
through a series of movements as if he were dealing cards. If
you hold out your hand to him as if to receive the coins he will
perhaps shake hands with you.
Ideational inertia is sometimes observed in apraxia, as in imper-
ception. The following excellent example has been recorded by
Dr. S. A. K. Wilson. The patient was given a match, which he
recognized as such. He was then asked “ How would you use
it ?”’ He replied “I would strike it, like that’ (imitating the
movement). He was then shown a pencil, which he also recog-
nized. On being asked how he would use it, he replied “ I would
strike it, like that ’’ (again performing the movement of striking
a match).
A patient of mine was shown a lens. He called it an eye-
glass and put it to his eye. He was now shown a penknife;
he called it a penknife but put it to his eye as if to look through
it. He was next shown a pencil; he recognized it as a pencil,
but put it to his eye, like the other objects (perseveration).
Apraxia is a very characteristic symptom of chronic cortical
atrophy from senility, arteriosclerosis or syphilitic endarteritis.
It is met with in post-epileptic states and during the recovery
of general paralytics from apoplectiform attacks. It is also seen
154 MIND AND ITS DISORDERS
in states of exhaustion, in acute and subacute alcoholism and
in severe cases of the polyneuritic psychosis.
Apraxia is a good illustration of the principle that dissolution
is a reversal of evolution. In every child, and indeed in every
adult, there is a certain amount of difficulty or disability in per-
forming a new, unpractised voluntary action; and apraxia is
a reversion to this condition, but it differs in that there is dis-
ability in the performance of well-practised voluntary actions.
When my housemaid takes upon herself to place my tennis-
racquet in its press she inserts it at the side instead of at the
end of the press: this is an example of apraxia during evolution.
In functional and organic disorders of the middle motor level
(Rolandic area) there is paralysis of voluntary movement al-
though the patient has a clear idea of the movement he wishes
to perform, the motor ideational centre in the left prefrontal lobe
being intact. Such paralysis of voluntary movement occurs as
the result of coarse brain disease such as thrombosis, embolism,
hemorrhage, abscess, tumour etc., destroying the excitable
motor areas of the cortex.
Such lesions are usually of fairly rapid onset and cause local
paralysis. In general paralysis, on the other hand, there is a
slow, insidious, diffuse, chronic, progressive cortical lesion gradu-
ally destroying the cortical neurons, especially those subserving
the function of voluntary movement and there is corresponding
progressive paralysis of volition.
Among the functional mental disorders (biogenetic psychoses)
the most typical example of paralysis of volition is melancholia.
In severe cases of this disease the patient stands motionless and
silent and no voluntary movement takes place for weeks or
months together. This paralysis affects the muscles of the spinal
column and of the large proximal joints most, the muscles of the
hands and feet being affected to a very small degree or not at all.
In milder cases the patient merely complains that he is “ unable
to do things’’. As in most cerebral palsies, a certain amount of
rigidity accompanies this paralysis.
There is a form of katatoniac stupor in which a somewhat
similar muscular condition obtains. The patient stands motion-
less and silent, just like a melancholiac; but the rigidity is even
more marked and its distribution is uniform, so that the joints of
the hands and feet are as rigid as those of the shoulders, hips
and spinal column. This rigidity sometimes involves the face
muscles (Snautz- krampf).
Anergic stupor is another condition in which there is paralysis
DISORDERS OF INSTINCT | 155
of volitional movement. In this state the patient suffers from
peripheral anesthesia of the kind already described, so that
ingoing stimuli are usually insufficient to arouse the idea of
movement. It will be shown later that functional motor
paralysis also obtains in this disorder (ultimately of unconscious
origin).
The lack of volitional movement in dementia is largely due to
partial anesthesia, ingoing stimuli being insufficient to induce
the movement-idea.
Partial or complete anesthesia is also to be held responsible,
to some extent, for the paralysis of volitional activity occurring
in states of intoxication due to alcohol, chloroform, chloral,
morphine and allied drugs.
The paralysis in fatigue is due, as we have already seen, to
the accumulation of certain products of metabolism in muscle
substance.
Increase of volitional activity is commonly known as “ pressure
of activity’. In maniacal states this occurs mostly at the large
proximal joints (shoulders, hips and joints of the spinal column)
and it is probably due, as will afterwards appear, to irritating
toxins within the cortical neurons. In agitated melancholia
it occurs mostly at the small peripheral joints and is probably
due to irritating toxins circulating in the nutritive fluids which
bathe the cortical neurons. Similar pressure of activity occurs
in some cases of subacute alcoholism.
DISORDERS OF INSTINCT.
It was pointed out in the first part of this manual that in-
stinctive action is closely allied to, in fact the same thing as,
emotional reaction. The considerations of the last chapter
therefore pave the way for the study of the disorders of instinct.
These are excess and defect; and there are certain other disorders,
which may be called “‘ erroneous instincts ”’.
The instincts are increased in the early stages of general
paralysis, alcoholic insanity, epileptic insanity and cerebral
arteriopathy; and they are diminished in the later stages of these
diseases as well as in confusional and stuporose states, secondary
dementia, myxcedema and cretinism. They are also diminished
in melancholia.
Exaltation of the instinets occurs most typically in general
paralysis, in which the primitive motor system becomes dominant
on account of degeneration of the pyramidal tracts or regression
156 MIND AND ITS DISORDERS
of volition. The symptom would be explained psychologically
by saying that primitive acts of the unconscious become domi-
nant because they are less controlled or uncontrolled by the
conscious mind. The eating instinct is increased from the first,
and the patient gourmandizes, not because he is hungry but
because he is greedy. An increased sexual instinct often gets
him into trouble with the police authorities in the early stage
of his disease. The instinct of acquisitiveness shows itself in
kleptomania and the tendency to buy hundreds of superfluous
and unnecessary articles. In the terminal stages of the disease
some of the infantile instincts again become dominant: the
patient instinctively clasps objects placed in his hand and carries
them to his mouth, and perhaps the very last movement to
disappear is reflex sucking when an object is placed in contact
with his lips; but perhaps these are reflexes rather than instincts.
An increase of instinctive movements is also to be noted in the
epileptic and alcoholic insanities, but usually to a smaller degree
than in general paralysis. Of such a nature are the brawling,
screaming and aimless activity of alcoholic mania and intoxica-
tion. The same symptoms are to be observed in some states of
maniacal excitement, not perhaps with the same uniformity;
but there is the tendency to collect, the exaltation of the sexual
instinct and of the instinct to eat something, not necessarily
food, for some excited patients, especially those suffering from
katatoniac excitement, are often quite pleased to eat earth or
the grass of the field.
What may be regarded as an increase of instinctive activity
also arises in certain obsessive states. In these, actions may
arise as the result of imperative ideas. For example, a patient
has a feeling that his hands are dirty; he looks at them and sees
that they are perfectly clean, but this has no inhibitory action
on the original feeling that they are dirty and he feels compelled
to go and wash them. A fruitless struggle against such an
absurd compulsion goes on in the patient’s mind and he has no
peace until his hands are washed. Such activities invariably
have some symbolic meaning.
The morbid impulses are clearly allied to such states as the
above and we have already seen that all impulses are instinctive.
An irresistible impulse to act in a certain way occurs to a patient,
perhaps to strike his children, and the act is performed without
reflection and often without resistance. The patient recognizes
his own lack of inhibitory power and may ask others to prevent
him from carrying out the act.
INSANE CONDUCT 157
The psychological mechanism of all these impulses is the same
as that of morbid fears mentioned in the last chapter. Irresis-
tible hand-washing, for example, is usually symbolic of a desire
to have a cleaner mind or to wash off the stain of past misdeeds
committed by the hands; and the impulse to strike and perhaps
to kill one’s own children is an attempt by the unconscious to
fulfil an unconscious desire, the reason for which varies in dif-
ferent patients and can only be discovered by psycho-analytic
investigation.
Deficiency of instinctive action occurs most typically in melan-
choliacs. These patients not only lose the primitive instinct of
self-preservation; they even develop the idea of self-destruction,
they refuse food, the instinct of sociability disappears and the
sexual instinct is so far lost that melancholiacs not infrequently
believe they are impotent. This is sometimes traceable to un-
recognized homosexuality.
In dementia, including that of general paralysis, instinctive
action is diminished. First there is regression of volition, then
regression of instinct. The instincts of locomotion and of vocal-
ization are lost. Advanced dements do not play games and they
have no ambitions. The instinct of acquisitiveness, which has
probably, in the earlier stages of their disease, been strikingly
demonstrated by a tendency to collect rubbish, has now entirely
disappeared. At meal-times they have to be led to the table
and, when there, the attendants frequently have to see to it that
they eat the food which is placed before them—not because they
actively refuse it, but because it has no interest for them.
Many remarkable disturbances of instinctive action, erroneous
instincts, occur in dementia precox, especially in the katatoniac
variety. Negativism, for example, is a fairly constant symptom
of katatoniac stupor: it may also occur in states of exhaustion.
It is a curious condition in which any suggestion made to the
patient at once arouses the counter-suggestion. If a katatoniac
be told to step forward, he steps backward; if he be asked to
show his tongue, he compresses his lips; if he be told to go to the
dinner-table, he walks away from it. This symptom must not
be taken for perversity: the patient cannot help it, it is instinct
gone astray. Psycho-analytically it is perhaps a “ resistance ”’.
Stereotypy is a symptom seen mostly in dementia precox, but
also in confusional states. This isa condition in which the patient
constantly repeats the same movements for long periods together;
he will repeat to-and-fro or rotatory movements with his arms;
he may walk up and down the same patch of ground for hours
158 MIND AND ITS DISORDERS
together, or in circles or figures of eight. The so-called man-
nerisms of dementia precox are closely allied to stereotypy:
one patient will keep an arm stiff, another will always hold his
legs straight when in the act of sitting down or rising from a
seat, another will drop on all-fours several times a day. These
patients are quite unable to give any reason for such antics;
they are merely instincts gone astray. Of course, these actions
are not so meaningless as they would appear to be; there is an
unconscious reason for every one of them, though extremely
difficult to ascertain in this particular class of patient.
Automatic obedience is another symptom seen mostly in
dementia przcox, but also occasionally in some states of con-
fusion. A patient showing this symptom will, if touched under
the chin, raise his head and keep it raised for a minute or so;
if touched on the top of the head, he will flex his neck again;
if gently pushed from behind, he will take a few steps forward,
and soon. A special form of automatic obedience is eehopraxia.
A patient showing this symptom will perform any antic which
another person takes the trouble to perform in front of him: if
you raise your arm, he will raise his; if you protrude your tongue,
he will protrude his; if you jump, so will he.
By constant repetition many of the above instinctive acts of
the insane become, in the course of time, automatic. Klepto-
mania, masturbation, wet and dirty habits, touching objects
(folie de toucher), the antics of the katatoniac and even the
tearing of clothes may all become habitual. In a few patients
(usually hypochondriacal melancholiacs) even the refusal of food
degenerates into a habit. I have known several patients who,
rather than take food in the usual way, would three times a day
regularly for months at the bidding of the doctor pass an ceso-
phageal tube on themselves and pour down a feed of milk and
eggs or broth.
DISORDERS OF SPEECH.
These occur in parallel with the disorders of action in other
departments. In stupor, melancholia, dementia, fatigue etc., in
which there is paralysis of voluntary action, there is paralysis
of speech and the patient is silent or nearly so. In the motor
excitement of mania there is noisiness and garrulity. Corre-
sponding to stereotypy we have verbigeration in which the
patient repeats the same sentence hundreds of times in the course
of a day. Mannerism of speech shows itself in stilted modes of
INSANE WRITING 159
expression. Corresponding to echopraxia we have echolalia in
which the patient repeats everything that is said to him, with or
without change of pronoun. For example, the doctor asks “* How
are you to-day ?”’ and the patient replies “‘ How am I to-day °”’
and corresponding to the antics we have in the domain of speech
a symptom for which I have proposed the name pseudolalia.
Patients presenting this symptom apparently pretend to speak;
but in reality they utter a series of meaningless sounds, such
as “‘Camalaba, dink-a-di-dink, goosey-goosey-wadlum’’. The
reduplicative tendency of this mode of speech suggests that it
is of instinctive origin.
When a patient’s speech is of such a nature that another
person is unable to follow his line of thought, it is said to be
incoherent. Incoherence results from two causes: (1) The
patient is so lacking in voluntary attention that any chance
percept, such as the striking of a clock or a glimpse of the doctor’s
tie-pin, by arousing his instinctive attention diverts the current
of his thoughts; (2) the patient’s flow of thought is too rapid
to allow all the connecting links to be expressed in words; such
a patient is not incoherent to himself.
It will be observed that incoherence is not necessarily a sign
of insanity. If you stand by a person talking through a tele-
phone, he is probably incoherent to you because the connecting
links of the conversation are missing; but he is not therefore to
be regarded as insane.
The writing of the insane is disordered in exactly the same
way as their speech. Garrulous, voluble patients, who are
sometimes said to be suffering from “‘logorrhcea”’, often write
many sheets of foolscap daily (‘‘ graphorrhcea’’). Patients
suffering from stupor, severe melancholia, advanced dementia
or advanced general paralysis do not write at all. Incoherence
occurs in the writing of the insane, as it does in their speech,
and for similar reasons. Katatoniacs perform all sorts of tricks
with their writing, just as they do in other departments of volun-
tary action. Their style is apt to be stilted and circumlocutory.
They form their letters with unnecessary care or perhaps have
some fantastic alphabet of their own (pseudographia). Pseudo-
graphia may also occur as a form of apraxia (Fig. 22). Ideational
inertia may also be occasionally detected in the writing of an
apraxic patient (Fig. 23).
The writing of the general paralytic is characterized by the
omission or repetition of letters, syllables and words. This
symptom possibly depends on some functional disturbance of
160 MIND AND ITS DISORDERS
the visual-perception centre, since similar mistakes are to be
observed when the patient reads aloud; he omits some words
and inserts others which are not to be seen on the page before
him. |
Writing is a recently acquired attainment in the history of
the human race and individual and is therefore one of the earliest
attainments to become disordered in all acute dissolutions of the
nervous system. Accordingly we find that one of the earliest
Fic. 22.—APRAXIC PSEUDOGRAPHIA.
Envelope addressed by an arteriopathic dement to his wife.
symptoms of an acute attack of insanity is deterioration of
the patient’s calligraphy and of the art of expressing himself in
writing.
Reaction-Time.—Many investigations have been made upon
the reaction-times of patients suffering from mental disease and
it has been found that their reaction-time for all mental pro-
cesses 1S invariably longer than natural. The greatest respect
is due to those who have carried out these laborious investiga-
APRAXIC WRITING
MIND AND. ITS DISORDERS
DISORDERS OF ATTENTION 163
tions, but their results must be regarded as valueless. Every-
body who has worked in a psychological laboratory knows that
it takes months of practice to become a competent subject for
psychological experiment; and it is for this reason that the
We obs Lino thee sh pene -
Send ne avo Sree cough dre he
Fan kink of pusrcele you mar be abe
ls gut “Than, URE Siecene
FIG. 24.—SENILE WRITING.
results obtained from patients, who have little or no such previous
experience, must all be discounted, apart from the fact that
the reaction experiment per se throws no light upon mental
processes.
DISORDERS OF ATTENTION.
Since attention is a special form of action our study of dis-
ordered action has prepared the way for the study of disordered
attention.
Inasmuch as a strong will is the essential characteristic of
a strong and stable personality, excessive voluntary action in
a strict sense can never be a symptom of mental disorder; and
therefore there can never be such a condition as excess of volun-
tary attention. If, on the other hand, it is contended that such
a condition may occur, it cannot be a symptom of mental dis-
order. ,
Defect of voluntary attention (aprosexia) occurs in exactly the
same conditions as defect of volition in general. These are, as
we have already seen, states of exhaustion, melancholia and all
forms of stupor, imbecility, and gross lesions of the cerebral
cortex in the neighbourhood of and especially anterior to the
motor areas. Defect of voluntary attention is noticeable from
the first and is steadily progressive in such diseases as general
paralysis, cerebral arteriopathy and other forms of dementia.
164 MIND AND ITS DISORDERS
Just as we found, in the previous section, that deterioration
of volition is accompanied in most cases by exaltation of in-
stinct; so we find that defect of voluntary attention is, in the
first instance and in most cases, accompanied by exaltation of
instinetive attention (hyperprosexia). In states of excitement
occurring in the infection and exhaustion psychoses the patients
are incapable of voluntary sustained attention to the doctor’s
remarks, but the clink of his keys or a glimpse of his watch-chain
suffices momentarily to arouse instinctive attention. One of the
chief difficulties in educating an imbecile is his incapacity for
sustained voluntary attention; his attention must be aroused
instinctively and the possibility of chance percepts reduced to
a minimum, for even a fly crawling across the window-pane
suffices to divert the current of his thoughts, by claiming his
instinctive attention. Instinctive attention is excessive in the
earlier stages of all mental disorders in which voluntary attention
is deficient, with the exception of melancholia and some forms
of stupor.
The importance of “‘ interest ’’ in determining which percepts
and ideas will stimulate instinctive attention is well illustrated
in patients suffering from delusions. Delusions are usually of
such a nature that the object of delusion invariably claims the
patient’s instinctive attention. This state of affairs is seen in
a characteristic form in paranoia, in which the patient’s whole
attention is centred on some particular fad or fancy.
Diminution of instinctive attention occurs in melancholia and
in all forms of advanced dementia and stupor. These include
anergic stupor, katatoniac stupor and the stupor associated
with some states of exhaustion.
Reflex attention appears to be increased in some patients and
diminished in others; but it has not yet been ascertained with
which mental disorders the increase and diminution are respec-
tively associated.
Maniacal and some other excited patients are easily startled
and many neurotic persons also complain of this symptom.
CHable kay i:
ERRONEOUS JUDGMENTS (DELUSIONS).
DELUSIONS are not only full of interest from a medico-psycho-
logical standpoint, but they are all-important from a legal point
of view. Many abnormal states of depression and excitement
do not appeal to the legal mind as states of insanity; but, if it
can be shown that a patient suffers from an absurd delusion,
a court of law is readily convinced of his insanity.
Delusions are not necessarily a sign of insanity. We all have
our delusions, but we are not all insane. Some people believe
that thirteen is an unlucky number, others believe that this is
not so. One of these two classes of people is suffering from
a delusion; but, whichever class this is, they are not insane.
Similarly the natives of Central Africa hold many judgments
as true which are regarded by civilized people as delusions, but
these Africans are not therefore to be regarded as insane.
Children are not insane when they believe that their dolls are
hungry or suffer from an illness, but such ideas in an adult would
amount to insanity.
It thus becomes necessary to make a distinction between sane
and insane delusions. An insane delusion is usually defined as
a judgment which cannot be accepted by people of the same class,
education, race and period of life as the person who expresses it.
It has been objected that, according to this definition, every
man who has some new and great truth to communicate to the
world is to be regarded as insane. This is not the case, how-
ever; for every such man has achieved his particular discovery
by prolonged study of the special branch to which it belongs.
In other words, he is of vastly superior education, in that par-
ticular branch, to the rest of mankind. When Darwin pro-
mulgated his doctrine of the descent of man he was regarded
as little short of insane by the proletariat; but those biologists
who had more nearly approached his standard of education
and were therefore most competent to judge were the first to
accept his conclusions.
165
166 MIND AND ITS DISORDERS
It would serve no useful purpose to give a complete list of all
the delusions that have been encountered among the insane,
even if it were possible to make such a compilation; but the
student will gain some idea of the commonest delusions from the
following list:
A patient may believe
That something dreadful is going to happen to himself or
his relatives.
That he is going to be hanged or burnt.
That nobody cares any more for him.
That he is deserted by God and eternally damned.
That he has committed “ the unpardonable sin ”’.
That he has committed a great crime.
That he will lose all control of himself.
That he has a hole in his head or in his back.
That his brain has gone.
That his throat is blocked up.
That his bowels are obstructed.
That his legs are paralyzed or made of glass.
That he is made of wood.
That he is an animal—a sheep, a wolf or a bird.
That he is only a few inches high and weighs but a few
ounces.
That he is miles high and weighs tons.
That he is God or Christ.
That he is the rightful heir to the throne.
That he is the King, or the Emperor of China.
That he is engaged to a great lady.
That he is a millionaire or that he is ruined.
That he is persecuted by means of electricity, hypnotism
or ““ soreerism ’’.
That there is a systematized conspiracy against him, extend-
ing over the whole of the civilized world.
That he is unworthy to live.
That he will never die.
That he is dead.
That he has “ cataracts’ in his head.
That the asylum is a Jesuit establishment.
That the other patients are of the opposite sex.
That he is a musician or poet.
That he can raise the dead.
That he is the strongest man in the world.
INSANE DELUSIONS 167
This list, which could probably be multiplied a thousandfold,
accentuates the fact that every individual, including every
mental patient, has his own peculiar mode of thought, which
must obviously depend upon his own particular experience of
life, differing from that of every other person.
However absurd such delusions may be, no amount of argu-
ment will serve to convince the sufferer of their unreasonable-
ness. The old proverb that—
‘A man convinced against his will
Is of the same opinion still,”
is more true of the insane than of any other class of the com-
munity.
The delusions of the insane have hitherto been regarded as of
little diagnostic value; but, to an understanding psychologist,
they throw much light upon the mode of thought of the patient's
unconscious mind. Delusions are analogous to or, in a way,
identical with dreams, the difference being that a deluded person
lives his dream. A dream is the fulfilment of an unconscious
wish, usually in distorted form. So is a delusion, and it is at
least a matter of psychological interest to determine how any
particular delusion has arisen. The physician who makes a
point of ascertaining this as often as possible will find that
he gains thereby a clearer insight into his cases and a more
powerful grasp of the subject of insanity in general. Further,
the physician should take pains to ascertain all the delusions
from which his patient is suffering, if only to avoid hurting his
feelings by chance remarks having apparent reference to his .
fancies.
The causes of a delusion are of two kinds, predisposing and
exciting. The predisposing cause is the patient’s mood, usually
determined by the unconscious mind. If he is in a state of
depression and misery, he is prepared to believe that he is to
undergo the most horrible and excruciating tortures that can be
devised. Ifa poor man is ina state of happiness, joy and elation
never before experienced, he is ready to believe that he is a
person of influence and importance and that he is possessed of
untold wealth: “ the wish is father to the thought’. If a person
is in a constant state of suspicion, he sees hidden meanings in
commonplace incidents and is prepared to believe that everyone
is against him and is persecuting him.
In many cases it is impossible to discover any other than this
emotional predisposing cause of delusion, but exciting causes are
168 MIND AND ITS DISORDERS
also at work in the majority of cases. Of these the most frequent
are hallucinations. This will be readily understood, for if a
person is not to believe the evidence of his senses, what is he to
believe 2? If he hears voices over his head, what more natural
conclusion than that there are people in the room above? If
God appears to him in the heavens, it is not very unreasonable
for him to conclude that he is ‘‘ the elect of God ’’; and if his
food tastes bitter, it is fairly rational for him to believe that
it has been drugged. Of course, such hallucinations are un-
consciously created by the patient, just as his delusions are.
Many patients arrive at an erroneous judgment by exaggerating
the ordinary symptoms of their disease. Melancholiacs always
suffer from severe constipation and many conclude from this
symptom that their bowels are permanently obstructed, especi-
ally if they have the “ epigastric sensation ’’ at the same time.
The chief physical basis of melancholia is a slight double hemi-
plegia of functional origin; hence many patients develop the
notion that their legs are permanently paralyzed. As we have
already seen, melancholiacs lose the function of emotional reaction
as well as the power of voluntary movement (popularly known as
“the will’’); hence they conclude that they have lost their soul
and are deserted by God, that they must have committed the
unpardonable sin and that they are eternally damned.
Memory defects are responsible for a certain number of delu-
sions, especially erroneous ideas of time and place. The follow-
ing case is probably an example of a delusion taking its origin
in a temporary lapse of memory: A gentleman was returning
from Paris to London. Shortly before he arrived at Calais he
fell into an epileptic state (so-called masked epilepsy), but con-
tinued his journey. When half-way across the Channel, he
jumped overboard. The only person who saw him do so was a
middle-aged lady, who straightway had an attack of “‘ hysterics ”’
and did not tell the crew what she had seen until it was too late.
The patient was a strong swimmer, was picked up by another
boat and ultimately taken to Chartham Asylum. Now he has
no memory of his remarkable experience, nor does he remember
leaving France; consequently he believes that he is still on the
Continent and that the various institutions in which he has been
lodged since his return to these shores are English kidnapping
establishments in the middle of France.
The normal tendency to the “ unity of ideation ’’ plays an im-
portant rdle in the origin of delusions, as may be shown by the
following examples: A patient was looking down the trap of a
———————
INSIGHT 169
drain in the garden when he heard a voice (in hallucination) ;
he thought that the voice proceeded from the drain and there-
fore that there was somebody down there. Another patient was
watching the movements of a blackbird a few yards from him,
when he heard in hallucination the remark “‘ You d——d fool !”’
He concluded that it was the bird that had insulted him. A
patient suffering from the epigastric sensation had hallucinations
of hearing; the conclusion was that the voice proceeded from his
abdomen and that he had a devil in his inside. A woman was
in the habit of seeing faces in the fire. One day, just after she
had seen the outline of her husband’s face in this way, she was
taking meat out of the oven when she heard his voice in hallu-
cination. Her conclusion was that the meat was human flesh
and that she had cooked her husband.
From these examples it will be seen that the erroneous judg-
ments of the insane are not so illogical as they appear at first
sight. That their reasoning is not in accord with the strict laws
of logic is obvious; but there would be no advantage in classifying
delusions according to the nature of the particular logical fallacies
of which the patient has been guilty.
As with the man in the street, there is no logical fallacy of
which the insane may not be guilty at times; but there is one
fallacy which is essential to a patient suffering from a delusion,
viz., the ignoratio vel ignorantia elenchi, ignorance of the main
question. The main question with patients suffering from de-
lusions is that they are insane. If they were to realize that
they are suffering from delusion, the delusion would tfso facto
cease to exist. The majority of the insane fail to recognize
that they are suffering from mental disorder, but a few have a
certain amount of “ insight ’’ into their condition.
INSIGHT.
It is rare for a patient to have any insight into his own mental
condition at the onset of a first attack of insanity; but a large
number of patients are capable of appreciating the nature of
their malady when it is explained to them or when they find
themselves placed under care in an institution for the insane.
Such patients are said to have “ insight ”’.
We have just seen that all who suffer from insane delusions
lack insight; and from the investigation of patients we find that
the converse usually holds good, that those patients who lack
insight almost invariably suffer from an insane delusion, and that
those who have insight do not. Accordingly we find insight most
I70 MIND AND ITS DISORDERS
characteristically in cases of intermittent and periodic insanity,
other states associated with depression, the compulsion neurosis,
neurasthenia, acute and chronic intoxications and some of the
milder forms of imbecility, provided always that the patient has
no delusions and that the mental disturbance is not so severe as
to prevent his thinking at all about the matter.
Insight is characteristically absent in all forms of stupor
and confusion, secondary dementia, epileptic insanity, general
paralysis, fever delirium, collapse delirium and the severer forms
of idiocy; but it will always be found that the amount of insight
depends upon (a) the patient’s capability of coherent thought
and (d) the presence or absence of delusion.
DISORDERS OF SENTIMENT.
Inasmuch as sentiment is one of the latest acquirements of
the human race, it is not to be wondered at that it is very easily
and frequently disordered, both in the sane and in the insane.
Since a sentiment is the voluntary formation of a judgment
as to the presence or absence of truth in a statement, beauty in
an object or morality in an action, it follows that sentiment
is deficient in all those conditions where volition is deficient,
where the volitional system is more or less in abeyance, either
from functional disorder such as melancholia and stupor or
from organic degeneration of the pyramidal system as in general
paralysis.
Max Nordau regarded some of the works of Rossetti, Burne-
Jones, Wagner, Swinburne, Tolstoi, Ibsen, Gautier, Zola and
many Others as productions sufficiently anti-zsthetic to justify
him in stigmatizing these great men as degenerates. There are
not many who agree with him and even Max Nordau himself
stops short of suggesting that such men should have been placed
under treatment for mental disorder.
I have never heard of a patient being sent to an asylum merely
because his artistic productions betrayed a lack of esthetic
sentiment or of an unscientific person being confined on account
of his deficiency of intellectual sentiment; but if a patient’s
conduct is immoral and therefore antisocial, the law may demand
that he be placed under restraint. If he be regarded by the
law as irresponsible for his immoral actions, the restraint is in
an asylum for the insane; if responsible, in gaol.
As we have already seen, morality is nothing more or less than
an innate desire to comply with the customs and desires of one’s
fellows. This instinct is the last to be acquired by the human
DISORDERS OF SENTIMENT Lak
race, as compared with such universal animal instincts as those
of nutrition, self-preservation and sex. Morality has also been
defined as the foregoing of immediate pleasure for the purpose
of gaining enhanced benefits in the future; in other words, it is
the voluntary suppression, for the purpose of future gain (or
for the avoidance of future pain), of the tendency to immediate
instinctive action. Immorality then is the letting loose of
instinctive action owing to defective volition. Immoral acts are
therefore liable to occur in all progressive degenerations of the
nervous system, because the more recently evolved volitional
motor system (the pyramidal tract) suffers dissolution at an
earlier date than the unconscious instinctive (cortico-rubral)
motor system.
Accordingly we find immoral acts occurring in early general
paralysis, chronic alcoholism, epilepsy, acute alcoholic intoxica-
tion, in the earlier stages of cerebral arteriopathy and in other
forms of dementia. We often read of a highly respectable
citizen, previously of unimpeachable character, being sentenced
to a term of hard labour at the age of sixty-five for some act of
immorality. His arteries are degenerate, his volitional nervous
system begins to fail him and his personal instincts are therefore
uncontrolled. The saddest thing of all is that no amount of
expert evidence will convince the judge that this is a consequence
of the arterial degeneration of old age.
In idiots and imbeciles voluntary control is never completely
developed; if their pyramidal system develops, it is a weakly
functioning apparatus. In some cases (moral imbeciles) im-
morality is almost the only symptom of mental disorder. Prob-
ably the difference between these patients and habitual criminals
is only one of degree.
entiment is deficient in all states associated with anesthesia
and imperception for the same reason that emotional reaction
is diminished in such conditions (see p. 150). It is accordingly
deficient in organic disease of the ideational areas, in cases of
confusion and stupor, in secondary dementia, senility, myx-
cedema, cretinism and idiocy.
On the other hand, patients suffering from acute mania and
paranoia are always ready to pass judgment upon the sayings
and doings of others, as every medical officer of an asylum well
knows; he hears many home-truths during the course of his
morning round.
In many cases of obsessional insanity (folie de doute) there is
marked exaggeration of sentiment. Such patients have to be
172 MIND AND ITS DISORDERS
reassured again and again that such and such a statement is true
or false, as the case may be, or that they themselves have made
their meaning clear and not made some false statement. They
have to be constantly reassured that they have not “ done the
wrong thing ’’; and whether an object is beautiful or ugly may
be to them a positive source of worry.
It will be observed that all these cases of exaggerated senti-
ment are associated on the one hand with hypersensitiveness or
on the other hand with motor excitement.
I have already hinted, in the section dealing with erroneous
judgments, that a patient’s belief in them is often rational.
Nevertheless, instinctive belief plays an important role in a
patient’s conviction of the truth of his delusions. .
CHANGED PERSONALITIES.
When we attempt to form a concept of the personality of an
individual suffering from an attack of mental disorder, a concept
of his “‘ ego ’’, there is no doubt in our own minds that the very
fact of his being insane changes that personality. Much more
must we suppose that, from the point of view of the patient,
there is a vast change in his personality, were it possible for him
to examine it.
Occasionally we come across cases in which the personality
is so far changed that the patient becomes an entirely different
individual. His very identity is changed, as also his ordinary
habits and instincts; his voice and manner of speech, even his
calligraphy becomes that of another person. He does not
answer to his own name, this too having altered; and if he be
questioned about the person bearing that name, either he never
knew such a person or his knowledge of him and his habits may be
of the foggiest nature. Some such patients pass through three
or more different identities; indeed a few years ago an account
appeared in the Journal of Mental Science of a patient who had
aS many as eleven personalities at different times, and I have
had a patient with eight.
Such changed personalities are usually revealed by hypnotism,
but quite commonly they appear as the effect of disease alone.
It should also be added that hypnotism may be responsible for
their creation. In some cases the subject or patient is merely
converted or restored to her (they are usually women) former
self at an earlier age, as in the case of retrograde amnesia men-
tioned on p. 144; in other cases the change is more complete.
In any case the new personality is to be regarded as a permanent
SEX AND STATION 173
subconscious state which is merely revealed by effacement of
the existing personality, the subconscious state becoming mani-
fest by temporary obliteration of phenomenal consciousness. A
submerged part of consciousness (subconsciousness) is allowed to
come to the surface. Dr. Frederick Myers’ iceberg analogy may
help to make my meaning clear.
If the whole of the visible portion of an iceberg were removed,
one-tenth of the remainder would rise above the surface and
present an entirely new aspect: and if this newly visible part
were removed, one-tenth of the remainder would as before rise
above the surface and present another new aspect. Nevertheless,
the submerged nine-tenths would, if they were visible, give the
appearance of a base for a superstructure. In some instances,
however, the removal of the visible portion would so upset the
balance of the whole that the mass would make an extensive
revolution and its new appearance have no similarity whatsoever
to the original.
So it is when phenomenal consciousness is abolished. Insome
patients one can discern a basis for the superstructure; in others
the subconscious part of mentation which becomes manifest
presents no resemblance to the original personality.
SEX AND STATION.
Nobody can go round an asylum without being struck by the
difference between the insanity of men and women. The greater
tendency of women to motor reaction is strikingly demonstrated
both in excited and depressed states. Maniacal women are
more noisy, more excitable and give much more trouble than
maniacal men; and the motor symptoms of melancholia are
always more easily observed on the female than on the male side;
the women are more liable to be stuporose and, when agitation
occurs, more agitated.
In accordance with the greater tendency of women to fatigue
we find that the insanity of exhaustion occurs more frequently
in them; but it must not be forgotten that they are especially
liable to such physiological processes as childbirth and menstrua-
tion, which are apt to lead to exhaustion and may be unduly
prolonged or associated with profuse hemorrhage.
The anesthesia which I have described as being especially
associated with mental disorder is more frequently found and
is usually more extensive in women than in men.
There is also an interesting sexual difference in the nature of
delusions. Egoistic man develops the delusion that his bowels
I74 MIND AND ITS DISORDERS
are obstructed, that he is dead, that he is going to prison or that
there is a huge conspiracy against him. An unmarried woman
is apt to develop similar delusions. But the altruistic married
woman's care is all for her husband and children. She hears her
children’s cries as they are being burned or otherwise tortured,
she fears that she has injured others, that she has not been a good
wife and mother or that she may never again be able to tend her
husband and children.
Insanity occurs rather more frequently in men than in women.
This is especially the case with general paralysis for reasons which
will subsequently be considered.
At the present time there are no statistics of the relative
frequency of insanity in the lower and the educated classes,
because it is difficult to ascertain the proportion which the
educated classes bear to the general population. A visit, how-
ever, to a number of county and private asylums leaves no
doubt in the mind of the most casual observer that the motor
reaction of county patients is greater than that of private patients.
The excited patients of the former class are more garrulous and
noisy than those of the latter. This, of course, does not betoken
a difference in the character of the mental disorder of the two
classes; the lower classes are naturally more garrulous and noisy
than the educated, but this characteristic restlessness of insane
patients of the lower classes is especially liable to lead to fatigue
and exhaustion and thus to prejudice their chances of recovery.
THE COMPREHENSIVENESS OF MENTAL DISORDER.
At the end of the section on normal mentation it was stated
that the various faculties of mind are interdependent. It follows
as a corollary that no faculty of mind can be disordered without
the others being also affected, at least to a slight extent.
For example, a person suffering from disorder of perception
cannot be regarded as fully capable of reasoning about objects
of perception in his environment. Further, disorder of percep-
tion is liable to affect the conduct in some measure. Again, take
the case of a patient suffering from some insane delusion. This
is bound to affect his conduct in many ways, and it is a matter
of experience that such a delusion tends to colour the patient’s
memory of incidents which occurred long before the delusion
existed. Loss of memory per se warps a patient’s judgment
concerning things forgotten, and even concerning things asso-
ciated with things forgotten.
COMPREHENSIVENESS OF MENTAL DISORDER 1s
We cannot regard any “ part ’”’ of mind as being affected alone.
Mind is not a “ thing ’”’ to be divided into “‘ parts’: mentation
is a process dependent on the functioning of the whole cortex
cerebri and any disorder of this function interferes with the
process of mentation as a whole.
Nevertheless, we are bound to admit that disorder of a given
mental faculty in one direction does not necessarily imply
disorder of that faculty in all directions. A man may be in-
capable of recognizing some objects but quite capable of recog-
nizing others; he may be able to remember incidents of one kind
but not those of another; and his conduct may be quite abnormal
in some situations but perfectly normal in all others. In like
manner, a patient’s judgment may be warped in one direction
only. It does not follow that, because he is suffering from some
insane delusion, his judgment on all other matters is erroneous.
He may fancy that he is the prophet Jeremiah and yet be quite
capable of transacting an important piece of business; he may
think that the earth has gone out of its course and yet make
a reasonable will or he may believe that he is the victim of
worldwide conspiracies but at the same time be capable of
solving the most abstruse mathematical problems.
GHAPTIE Rey iE
PSYCHO-ANALYSIS.
PsYCHO-ANALYSIS, to which frequent reference has already been
made, is best described here because we shall have to refer to it
again when describing the various mental disorders, although
its proper place is perhaps at the end of the book, because it is
a method of treatment.
Although psycho-analysis is commonly regarded as being a
recent growth, it is the outcome of more than thirty years of
laborious scientific investigation by Professor Freud of Vienna,
who is undoubtedly the greatest living psychologist, in my
opinion the greatest psychologist the world has known, and
still contributes much to our knowledge of the science.
Essentially psycho-analysis is his method of investigating the
unconscious mind of a person, usually of a patient, so that he
can discern the unconscious origin of his symptoms and thus
dispel them. It is mainly applicable to the neuroses, psycho-
neuroses and, in smaller degree, the biogenetic psychoses; but it
will be seen later that symptoms arising in even the organic
insanities can be explained on _ psycho-analytic principles.
Moreover, psycho-analytic principles must ultimately be taken
into account by general physicians, clergymen, teachers,
criminologists, sociologists and all those who are concerned
with the study of human thought and conduct. We venture to
hope that these will always bear in mind that they owe this
knowledge to medical science and that any attempt to divorce
modern psychology from medicine must prove fatal to their
cause. It appears also to be necessary to utter a warning that
those who intend to study this subject should take it seriously .
and not dabble in it.
Psycho-analysis has met with much opposition, not only on
account of its novelty and the universal tendency to accept
traditional rather than experiential knowledge, but also on
account of several misapprehensions. Being a mode of psycho-
therapy, it is supposed to be something like hypnotism, in which
the physician imposes his will on the patient, whereas nothing
176
OPPOSITIONSTO SPs YCHO-ANALYSIS Las
is farther from the truth, for the psycho-analyst plays rather
a minor réle in the treatment. As already stated, psycho-
analysis is a method of investigating the unconscious mind of
a patient, and the only person who has access to this is the
patient himself. It is therefore the patient who does all the
talking while the physician tells him absolutely nothing; the
function of the analyst is merely to instruct the patient in the
technique and to keep him to it. Psycho-analysis is the only
branch of medicine in which the doctor so scrupulously, strictly,
and even strenuously, refrains from telling the patient anything
about himself or giving instructions as to his mode of conduct
and manner of life. :
Another objection is that the psycho-analyst assumes the role
of a priest in the confessional and that any beneficial results of
the treatment are due to the patient having unburdened his
mind and shared his sorrows with another. It is perfectly true
that an essential point in the technique is that the patient should
tell the doctor everything that comes into his mind; but the
reason of this is not that he must confess it to the doctor, but
that he should acknowledge to himself thoughts and desires
which he has hitherto failed to recognize.
The factors, however, which have aroused the most hostile
criticism are that Freud and his school claim that psycho-sexual
functions play the most important rdéle in the causation of the
neuroses and, worse, that psycho-sexual activities can be traced
back into the early years of childhood.
We deal with the latter objection first because it is based on
a misapprehension. Freud agrees with us all that the child has
no conscious knowledge of sexual activities, but he does designate
as sexual any activities of the child which would be regarded by
everybody as sexual if they occurred in an adult. One of my
patients began unmistakable acts of masturbation when she was
eight months old and continued them until at least her eighth
year; but during the whole time it is certain that she attached
to them no sexual valuation. Yet it is justifiable to regard them
-as sexual; the tendency to masturbate cannot possibly be ascribed
to any other instinct. The child is now thirteen years of age
and fairly normal. I had hoped that the tendency would have
no permanent effect on her; but unfortunately she has a foolish
mother who should never have been a mother, and the patient
has at times shown signs of nervousness.
The strenuous opposition to the view that psycho-sexual
trends are intimately related to the mental disorder is primarily
12
178 MIND AND ITS DISORDERS
due to sentiment, the general taboo of sexual topics and perhaps
an unwillingness to admit that we have hitherto been so foolish
as to allow such feelings to blind our eyes to reality. Long
before psycho-analysis, doctors used to prescribe marriage for
hysterical girls, without knowing why; yet they would not allow
themselves to trace their opinion to its source, probably because
they thought that it would not pay to have their names asso-
ciated with matters of sex. In bygone times gynecologists and
syphilographers were regarded askance and the older physicians
used to advise their protégés to eschew such specialisms.
Of all human activities, thoughts and conversations, none is
so much banned as the sexual, and this raises the question why
the sexual instinct in particular should be a very special object
of taboo. In seeking an answer to the question the first thought
which occurs to us is that a racial taboo must comply with—nay
more, its origin must be traced to—the wishes of the majority of
the units composing the race. We are therefore driven to seek
the origin of a racial taboo in the individual.
In the next chapter we shall consider numerous sexual per-
versions :—homosexuality, auto-erotism, sadism, masochism,
fetichism and many others. Such perversions are not rare; they
are common. Indeed Dr. Havelock Ellis, who is a great autho-
rity on such matters, estimates that 5 per cent. of the male
and ro per cent. of the female population are consciously homo-
sexual. This being but one perversion among a dozen or more,
it seems permissible to conclude that at least 25 per cent. of the
population, even at a moderate estimate, have some consciously
sexual perversion.
Now consider the fact that psycho-analytical investigation
invariably discovers some unrecognized and therefore unconscious
sexual perversion, and we are driven to the conclusion that
nobody is normal sexually. Most people naturally resent such
an intolerable notion and would stoutly deny that their sexual
instinct is abnormal. They would refuse to admit it even to
themselves, yet it would appear that somewhere deep down in
their minds their perversion receives recognition, and it is this
which causes every individual to have an instinctive aversion
from sexual topics; it is this which is responsible for the racial
ban which has in these latter days been extended to psycho-
analysis.
To some of the cardinal principles of psycho-analysis reference
has already been made in earlier chapters and now they need
only be mentioned again.
THE UNCONSCIOUS 179
Psychical Determinism.—tThe first is that mental processes are
‘ never fortuitous. No thought, no action, no dream, no act of
memory or of forgetting, no slip of the pen or tongue, no ap-
parently accidental mental event ever occurs by chance. There
are always reasons for them, viz., the circumstances of the
moment plus the whole of the person’s past experience of life.
Moreover, on the occasion of any mental event, no other could
have occurred at that moment; that thought or action and no
other was bound to occur.
The Unconscious.—We have to recognize the existence in each
one of us of an unconscious mind of which we are quite unaware.
It contains all those thoughts, memories, instincts and desires
which we refuse to admit to ourselves and, as the saying is, have
“put out of our minds’’. Really they are pushed deeper into
the mind. It also contains percepts, which have not been con- _
sciously recognized, innate trends which have never met with an
opportunity for recognition—for example, the maternal instinct
in unmarried women—and wishes which have never been allowed
to enter consciousness, which have never been conscious, such as
desire for the parent of the opposite sex (CEdipus-complex).
Inasmuch as the content of the unconscious is, for the most
part, the psychical material which has been banished from the
conscious on account of its lack of harmony with conscious
thought, it follows that the wishes of the unconscious are the
exact opposite of conscious wishes.
Our conscious aims are those of morality, altruism, honesty,
truth and virtue; but deep down in the unconscious of us all
are animal tendencies to licentiousness, egoism, robbery, deceit
and vice, however much we deny the fact. The conscious tends
to morality, the unconscious to immorality; but before we
discuss this basis for intrapsychic conflict, let us consider the
word “‘immorality’’. It has a very wide meaning, yet it in-
variably has a sexual connotation. Why ?
The reason is not far to seek. It is quite legitimate in a draw-
ing-room to talk of murder, theft and fraud; of topics relating
to the instincts of self-preservation and nutrition; but of rape,
infidelity and the sexual instinct—never! That is immorality
par excellence ; sexual matters are more repressed than all others
and it therefore follows that the content of the unconscious is
mainly sexual. This conclusion is directly verified by psycho-
analytical investigations.
In an earlier chapter it was explained that ideas are grouped
into constellations (so to speak). For example, any idea relating
180 MIND AND ITS DISORDERS
to the girl to whom a youth is engaged belongs to his constella-
tion of love ideas, all thoughts bearing on one’s necessity or
desire for attending social functions belong to the constellation
of society ideas, and so forth; but there are also unconscious
constellations of ideas. These are called complexes. |
Complexes constitute the greater part of the unconscious,
but it is not to be supposed that their repression into the un-
conscious does away with them for ever. Both conscious and
unconscious constellations urge the individual to do some par-
ticular thing; the love constellation constantly urges a person
to meet his mate, the society constellation urges him to attend
social functions and, in lke manner, a complex is constantly
striving to express itself in action.
Yet the conscious or subconscious (“‘ preconscious ’’ in Freudian
terminology) repression of a complex prevents it from obtaining
expression in an undisguised form. This continuance of the
original repression has been called by Freud “ the censure ”’ or,
by his American translators, “the censor’’. The translation
is rather apt in that it points to an analogy with the Censor of
letters during war time; disallowed information must be given
in disguise so that he cannot recognize its meaning and allows it
to pass; but it is necessary to state that there is no implication
that a personal imp sits somewhere on the cortical membranes
to fulfil this function, because some critics, including a well-known
psychologist (now deceased), have applied this interpretation to
the notion of the intrapsychic censor. A physiological term for
the function would be inhibition.
Simply stated, the facts are that complexes constantly strive
for recognition in the face of opposition; and they invariably
succeed in one way or another by means of disguise.
A complex may assert itself vi@ sublimation, replacement
reaction or symptom; also, as we have already seen, in dreams.
For example, let us take a maternal complex in an unmarried
woman and a homosexual complex in a man.
Sublimation is the diversion of the trends of a complex into
useful, social, moral and ethical directions. In the above ex-
amples the maternal complex may be diverted into attendance
at a créche, interest in societies for infant welfare or taking up
the nursing or teaching profession. A homosexual complex in
a man might be sublimated into an interest in boys’ clubs,
Sunday-schools for men or the Y.M.C.A., or, again, taking up the
profession of schoolmaster or choirmaster. The latter, by the way,
sometimes prove dangerous and lead the victim into temptation.
REPLACEMENTS AND REACTIONS I81r
Replacement is somewhat similar to sublimation, but replace-
ments subserve no useful or ethical function. I‘or example, it
sometimes happens that the maternal instinct in a grown woman
is displayed in an interest in dolls and that a male homosexual
wears corsets without knowing why he likes to do so.
Reactions are not direct outlets for complexes, they are con-
scious activities the very contrary of what the unconscious
desires; yet it would appear that this reversed kind of recogni-
tion of a complex serves to satisfy itin many cases. For example,
some homosexuals are sexual voués devoted to sensual and
licentious practices with members of the opposite sex, yet they
never marry. Similarly, people who have repressed a desire
to steal, which was evident in childhood, become scrupulously
honest and invariably pay every bill “‘ on the nail ”’.
These are all more or less normal ways of satisfying a complex,
but their methods are not always so direct and obvious as in the
examples given. All three may appear in symbolic guise. For
example, the homosexual complex may gratify itself by a habit
of striking trees, posts and other phallic objects or poking at
them with the walking-stick or umbrella (also phallic) when
the subject goes for a walk, the bringing together of two phallic
objects symbolizing homosexuality. A patient of mine, whose
homosexuality became patent during unconscious fugues, fol-
lowing a shell explosion, burial and subsequent disinterment by
another shell, dreamed that he broke his pipe (symbolizing the
penis) and next day actually snapped it in two between his
fingers, to his chagrin, and to all appearances, unintentionally.
In the dream he also lost a little white ivory spot (a trade mark)
from the mouthpiece; this symbolized semen. Those who are
familiar with psycho-analysis will here recognize a castration
dream and an action symbolizing self-castration.
Many will wonder why on earth the experience of this patient
should arouse his latent homosexuality. The explanation is not
far to seek if one cares to think symbolically; for a shell is a
long, penetrating, explosive thing, in short—phallic. After the
experience, his usual dream was of running away from a shell
which was chasing him, and dreams are invariably the fulfilment
of an unconscious wish.
Perhaps one of the best examples of sublimation in symbolic
guise is that of the feces complex. Babies are much more
interested in their excrement than is usually supposed; many
examine it and play with it and more would do so if opportunity
occurred. Later they like to play with mud pies, then sand,
182 MIND AND ITS DISORDERS
then putty or plasticine. This interest is not lost in adult life,
it is sublimated into an interest in money, which—in psycho-
analytic experience—we discover to be frequently associated
with feeces. Financial expressions often supply evidence of this
association :—we have a deposit or current account on a bank and
money is said to be either hard or fluid. There are also such
slang expressions as “‘ filthy lucre ’’, ‘‘ So-and-so stinks of money ”
or he is “‘ constipated’’, meaning that he is disinclined to part
with or that he sézcks to his wealth. A patient of mine dreamed
that she had passed feeces into her bed and that the sheet became
‘““water-marked like a bank-note’’. Another patient, a mil-
lionaire, had been excessively mean and constipated all his life.
He suffered from piles (another suggestive expression by the
way) and some clever proctologist had cured his piles and con-
stipation by two injections of something. He became immedi-
ately so generous, thriftless and extravagant that he was con-
sidered to be insane. Indeed it was for this symptom alone
that I was consulted. And this is just what we find:—that
constipated people are always anxious respecting the expenditure
of money, while those whose bowels are open regularly do not
worry about their financial affairs. It will not escape the reader
that constipation in an apparently normal person is the fulfil-
ment of an unconscious wish to retain feces. The evidence is
overwhelming and it must not be supposed that even a tenth
part of it has been given here; but it is because symbolism in
general is so unconvincing that this particular example has been
rather fully discussed.
Should a complex fail to be expressed in any of the above
ways, it becomes manifest as a neurotic or psychotic symptom.
In some cases it appears as a somatic manifestation, as in hysteri-
cal motor and sensory disturbances (conversion); in a second
class the affect which belongs to the complex becomes transferred
to some related but less repugnant conscious idea, which then
becomes a source of worry to the patient (substitution), as in
the compulsion neurosis; and, in a third class, the complex un-
acknowledged by the patient is ascribed to other people (pro-
jection), asin paranoia. These, which are merely a few examples
of the way in which a complex may reveal itself in symptomatic
guise, will be explained in more detail, and others will be men-
tioned in subsequent chapters as the various symptoms come
under discussion.
Last, but by no means least, we have to recognize that infantile
mental processes form the permanent basis for all later develop-
INFANTILE PSYCHO-SEXUAL TRENDS 183
ment. Mental energy, like physical energy, is indestructible.
Thoughts, memories and desires may be repressed into the un-
conscious, but they are never lost or destroyed. An instance
of this has already been considered in the sublimation of a childish
interest in feeces into an adult interest in money; and, since
Freud has demonstrated that the foundation of sexual life is laid
during the infantile period, we shall have to examine the develop-
ment of the sexual instinct.
Psycho-sexual Trends.—It appears to be necessary to repeat
insistently that psycho-analysts do not ascribe to the child any
knowledge of the sexual meaning of those of its activities which
to the adult mind have a sexual signification.
At the time of birth, the child passes out of its soft warm
comfortable bath through the most excruciating torture of
universal compression (with its head and face squeezed out of
shape) into a cold hard world where its first experience is that
of suffocation and none too delicate manipulation by relative
giants.
After this initial experience of fear, probably the greatest terror
a person ever suffers, any pleasure that it happens to find must
surely be greatly enhanced by contrast. Very early in life it
discovers that it has certain powers within itself, viz., those of
micturition, defecation and sucking, all of which give pleasure.
The three primary pleasure zones are then the neck of the bladder,
the anus and the mouth; and there is plenty of evidence to show
that these acquire in later life a sexual valuation which is usually
unconscious, but sometimes—and not very rarely—conscious.
Infantile sucking has indeed been compared with coitus, and
the subsequent flushing of the face, followed by sleep, with a
sexual orgasm.
It is not, however, merely for such a superficial reason as this
that sexual significance is attached to the oral phase of develop-
ment, as Freud has called it, during the first year of life; but
because we find during psycho-analysis that innumerable sexual
associations and characterological peculiarities trace back to this
period, wherein we find the beginnings of auto-erotism or self-
love. Most children like to rub various parts of their own bodies,
and some start masturbation at this time. The inner surface
of the thighs and the breasts are found to give pleasure on
manipulation mostly in female infants.
The phase of anal erotism follows that of oral erotism. The
child obtains physical pleasure in evacuating the bowels not
consciously sexual in the first instance, but found on subsequent
184 MIND AND ITS DISORDERS
psycho-analysis to have sexual associations in our character-
ological investigations. There is a second stage to this period,
when a certain amount of repression of this function is imposed
on the child by its nurse or mother, which may lead to a desire
to retain faeces and to the subsequent gratification of passing
a constipated bolus. The anal phase may be said to last during
the second and third year. Then follows the phallie stage, in
which the penis plays an important réle in the mind of the infant,
and this, curiously enough, occurs in both sexes—a fact which
renders the subsequent psychical development of the female
much more complex than that of the male. For example, we
find deep down in the unconscious mind of every female the
notion that she has become female by losing the penis (castration
complex). It is extraordinary, too, how frequently we find’a
castration complex in the male, owing apparently to threats
during early life of having the penis cut off. On the other
hand, this castration idea is sometimes self-imposed by the .
patient in consequence of the feeling of guilt induced by early
masturbation.
The fourth period, which lasts roughly during the fourth and
fifth years, has been called by Freud the genital phase, during
which the sexual organs achieve their more natural significations.
Then follows a stage of repression, lasting until puberty, which
Freud has called the “‘latent period’’. From puberty to adoles-
cence, however, we find that the same order of development is
carried out all over again, viz., the oral, anal, phallic and genital,
not so consciously as during the infantile period; but analysis
of the various activities occurring at this time of life proves them
to be founded upon the psycho-sexual significance of identically
the same eroto-genic zones. The tuck-shop, cigarettes and
chocolates afford occasion for manifestations of the oral activity
at this time, the anal phase is manifested chiefly by certain
sadistic and masochistic tendencies and activities, and the
pnallic phase by a recrudescence of masturbation, which is
clitoric in the female, not vaginal.
Freud has recognized, and everybody with psycho-analytical
experience has confirmed, that in addition to these main eroto-
genic zones (the mouth, anus, neck of the bladder, penis, clitoris,
inner surface of the thighs and breasts) many other organs of
the body contribute to psycho-sexual development. In short
the child passes through numerous sexual perversions in minia-
ture during its development, and this fact has caused Freud to
designate the normal child as being “‘ polymorph-perverse”’. A
PSYCHO-SEXUAL DEVELOPMENT 185
normal sexual instinct is ultimately achieved by repression of
the perversions in favour of the primary genital zone.
About the fourth year the hitherto auto-erotic child begins to
find an external object of love, firstly in the person of the mother
or her surrogate or the nurse, later in other members of the child’s
own family. Since psycho-analytical explorations have revealed
the fact that all love has a sexual basis, we are not misusing
terms when we point out that a girl’s love for her mother is
homosexual. Curiously enough, we often find that a boy’s love
for his mother is also homosexual at this age, especially in those
not infrequent cases in which he supposes his mother to be
anatomically fashioned like himself.
Asa rule, however, when the conduct of both parents is normal,
we find that, by the tenth year, the boy loves his mother and
the girl her father the more (beginning of conscious hetero-
sexuality).
During the early “ teens ’’ incest barriers are set up and a love
object is sought outside the family. In boys this is usually a
girl, but in most girls the love object is quite commonly a school-
mistress (replacing the mother) or some other girl until the later
“ teens ’’ when normal heterosexual trends develop.
Lastly, it has to be noted that, in the unmarried female, the
clitoris is the most sensitive sexual organ, and that marriage
normally has the effect of transferring this sensitiveness to the
vagina.
Now psycho-analysis has revealed that what is fundamentally
wrong with neurotic and psychotic patients is that they have
become fixated sexually in one or more of the above-mentioned
stages, that they have not grown up sexually, or that they have
regressed from what was a perfectly normal sexual development
to one of the infantile periods. In the neuroses the amount of
regression is almost negligible, in the psychoneuroses it dates
back to the latent period and in the psychoses the regression is
right back into the earliest years of infancy.
Of course the patient does not know that this is what is the
matter with him; even the manifestations of this undeveloped
stage are unacknowledged and repressed into his unconscious.
They appear in symbolic form only; and this fact, when con-
sidered in combination with the “ polymorph-perverse ’’ nature
of the normal child, affords the real explanation why a funda-
mental understanding (I almost wrote “ diagnosis ’’) of neurotic
and psychotic conditions is so extraordinarily difficult. Indeed
we have considered only symbolization; but all the mechanisms
186 MIND AND ITS DISORDERS
of dream distortion are at work in the creation of neurotic
and psychotic symptoms, including condensation, displacement,
representation of the opposite and dramatization.
As we have already remarked, a neurosis or psychosis is really
nothing more or less than living a dream. When, then, we
consider the difficulty of interpreting a dream with the aid of
the conscious mind of the dreamer, we can readily understand
the extraordinary difficulty in the interpretation of neurotic
and psychotic symptoms in those cases in which the patient is
incapable of rendering similar assistance.
TECHNIQUE.
It will already have been gathered that psycho-analysis is a
method of investigating the unconscious of a patient, or anyone
else for that matter. How can this be done ?
In the first instance, a person’s unconscious is inaccessible to
himself and it must necessarily be still more inaccessible to any
other person. It is obvious that the only one who has sufficient
knowledge of the patient’s individual experience and modes of
thought to throw a light on the matter is the patient himself.
This leads us to the first principle of psycho-analytical technique,
viz., that the patient must tell everything that occurs to his
mind to the analyst and keep nothing back.
As with all patients, whatever their ailment may be, the first
task of the physician is to take a detailed history of the case,
symptom by symptom, tracing it back, as far as may be possible,
to its origin. He obtains details of previous illnesses of every
kind, and endeavours to ascertain whether they have any rela-
tionship with the existing malady. Then follows an enquiry into
the family history, a little more detailed than is usual in general
practice, with a view to ascertaining the patient’s conscious
opinions respecting various members of his family.
Should any organic disease be discovered, this should be
treated by the patient’s usual medical attendant or by some
specialist in the particular malady, even though the patient be
suffering from an obvious neurosis; for it must never be forgotten
that ill-health of any kind is liable to weaken psychical re-
pression and thus to allow the unconscious to be more assertive
than usual, so as to produce intrapsychic conflict. The correc-
tion of an error of refraction, an abdominal support or the open-
ing of an abscess may suffice to restore the equilibrium between
the conscious and unconscious.
PSYCHO-ANALYTICAL TECHNIQUE 187
Having once established the fact that the case ought to be
treated by psycho-analysis, all other attempts at treatment
should cease. Even the analyst should refrain as much as
possible from prescribing drugs; but the patient should be left
entirely in his hands. It will be explained in the third part of
this manual which disorders are suitable for analysis. Broadly,
it may be stated that only the neuroses and psychoneuroses are
really suitable. Moreover, the patient must be fully capable
of apprehending that his malady is purely psychical in origin,
and he must be seriously willing to co-operate with the analyst
in attempting to get to the bottom of it. There are many who
present themselves for psycho-analysis ina light-hearted fashion
and make some sort of a beginning, but soon find all sorts of
reasons for interrupting the treatment. The experienced psycho-
analyst can usually recognize this type of patient and will devise
some excuse why the treatment should not be initiated. Other-
wise the patient will become one of the increasing number of
persons who go about the world proclaiming that they have
been psycho-analyzed (obviously without success) and_ bring
disrepute to the method.
When, on the other hand, a medical psychologist has decided
that his patient should be treated by psycho-analysis, it is a
necessary preliminary to explain that he will require the patient
to attend at his consulting-room for one hour a day six times a
week for probably a year, but that the treatment might be
completed in four months or require a longer period than one
year, possibly even two years. Arrangements having been
concluded as to times of attendance, fees and so forth, it is
permissible to tell the patient that his dreams can be of the
greatest assistance during the treatment. Dreams are so easily
forgotten (repressed) that some patients like to write them out
as soon as they occur. Personally I have no objection to this,
but some psycho-analysts think it bad technique.
It is also desirable to advise the patient that the first two or
three weeks must be regarded as tentative, for it is sometimes
discovered within this time that he is not really a suitable
case for analysis and that some other treatment should be
adopted.
The emotional reactions which occur during psycho-analysis
are often very severe and, during those stages when a complex is
revealing itself but not yet consciously recognized and admitted,
prolonged for days or even weeks. It is as well therefore to
forewarn the patient that there may be times when he feels
188 MIND AND ITS DISORDERS
worse for the treatment, but he is not then to suppose that psycho-
analysis is doing him:-harm. On the contrary, these are the
occasions when he is making real headway. |
All preliminaries having been settled, the patient begins his
daily visits. At these he should lie on a couch at the head of
which the doctor sits, the object of this arrangement being to
avoid every possibility of suggestion by the analyst, any move-
ment or change of expression on his part being thus concealed
from the patient while, on the other hand, the analyst can
~ scrutinize every movement of the patient. The latter is essential
because unpremeditated movements of the hands, fingers and
feet frequently give more reliable information than the organs
of speech. This is the orthodox posture of the patient, but it
is quite a common practice to place the patient in a comfortable
armchair with its back to the analyst, more or less.
After a brief reference to some unexplained item at the end
of the previous visit, the patient is told to allow his thoughts to
wander and without self-criticism to speak everything which
comes to his mind, even though it appear to be quite foreign
‘to preceding thoughts or betray a secret belonging to some other
person. No matter how painful or even disgusting any revived
memories may be, he must speak them out and tell everything,
the real object being, not so much that his psychologist should
know, as that the patient should recognize and acknowledge to
himself the various items of experience which thus occur to his
mind. Incidentally they may cause much emotional reaction
which the doctor should not attempt to allay, but rather en-
courage.* The doctor says as little as possible, but merely keeps
the patient to any line of association initiated by him (the
patient), enquires for more particulars or asks for explanations.
He tells the patient absolutely nothing and scrupulously avoids
suggestion of any kind. This method, which has been called
by Freud “ free association ’’, is the central principle of psycho-
analysis. It is, of course, permissible to repeat to the patient
precisely what he has said when he appears to have missed some
point or to comply with his request to give an explanation of
a psychical mechanism which has become obvious to him but
incomprehensible.
* It has been demonstrated that these emotional reactions are accom-
panied by changes in the pulse and respiration and by electrical phenomena
of various kinds. Academically these facts are of very great interest, but
the practising medical psychologist seldom, if ever, finds it expedient to
investigate such physical reactions in his patients.
“"“THE TRANSFERENCE © 189
The interpretation of dreams also plays an important part; in
fact, free association is the essential mode of discovering the
symbolic meaning of the various items occurring in a dream.
It is permissible to explain to the patient that his dreams, being
creations of his own phantasy, must of necessity represent situa-
tions for which he craves, lest he may be inclined to ascribe to
them a prophetic or otherwise mystical significance.
Freud has shown that a dream is invariably the fulfilment of
a wish, usually unconscious; but, owing to the preconscious
mechanism of the censure or “‘ censor’”’ above described, this
wish-fullilment is greatly distorted. It is this distortion which
necessitates an interpretation of the dream. The chief mechan-
isms of distortion have already been described on p. 100. We
must here, however, refer to a few more details.
The affect in a dream is never distorted; it is either the correct
one for the interpreted situation or its exact opposite. If, for
example, a normal girl dreams that her lover is unlocking her
hand-bag with a key, she is usually terrified (conscious reaction
to the situation after interpretation); but she may be pleased
and gratified (unconscious reaction); she is not angry, amused,
disappointed or disgusted.
The terror in such a dream would exemplify representation of
the opposite emotion, but this sometimes occurs in other dream
activities. It may be taken as a rule that when one dream fact
is inverted in this way, there is always another inversion some-
where in the dream:
The analyst is usually portrayed somewhere, usually in dis-
torted guise, as some other doctor, a clergyman, a pugilist, a
policeman, a fisherman or sometimes as an inanimate object—
a breeze blowing through the window, a shed or an instrument
of torture. These are a few personal examples, whose symbolism
I leave the reader to discern. The analyst “‘fishes’’ in the
mind of the patient, and I have appeared in the dreams of some
patients, not only as a fisherman, but also as Lord Fisher and
Dr. Fisher (the ophthalmologist). Perhaps the most amusing
dream-symbolism of myself as an analyst was “‘ a box of Keating’s
powder ’’ (something which kills the “ little worries ’’ of life);
the patient was a private soldier during the earlier days of
the War.
Transference.—From such dreams it may be gathered that
the physician is a person of great importance to the patient’s
unconscious. Indeed, it becomes evident in the course of an
analysis that the analyst becomes a substitute for various
Igo MIND AND ITS DISORDERS
persons who have in the past played the most important parts
in the patient’s life, especially the father and mother or their
surrogates. The patient’s unconscious mental activities towards
such persons become transferred to the analyst, the affect being
one of anger, fear, hatred, affection or even love. The patient
is encouraged to admit such feelings to himself, so that there
is abreaction of the affect with consequent dissipation of the
transference. In this manner he gradually becomes free from
all infantile fixations, grows up emotionally and is set upon his
own feet. Should this transference interfere with the progress
of the analysis it (the transference) should itself be analyzed and
thereby dissolved.
During the course of a psycho-analysis all sorts of difficult
situations may arise which demand great shrewdness from the
physician who has to deal with them. For example, certain
home relationships appear to be antagonistic to the treatment.
The difficulty can frequently be solved by analyzing the point
at issue through free associations. If the analysis temporarily
fails in this particular instance I am not usually in favour of the
patient seeking a solution in flight—e.g., living away from home;
for it is necessary that his neurosis should cease to exist, even
in the most unfavourable environment. When the physician
is confronted with such difficult problems as these, he will
act wisely if he consults some other medical psychologist of
experience. |
Other methods of exploring the unconscious are by hypnotism,
crystal-gazing and automatic writing. In most cases, however,
they fail to elucidate sufficient information to enable the physician
to cure his patient permanently. Only in recent cases, in which
the basal complex of the neurosis is not very deep, can much
assistance be obtained from these methods.
In a few instances I have succeeded in curing the patient by
using hypnosis as a mode of treatment after gaining sufficient
insight into the patient’s unconscious by a short analysis of two
or three hours; but cases suitable for this method are very
uncommon.
CHAPTER VIII.
ANOMALIES OF THE SEXUAL INSTINCT.
THE researches of Freud, considered in the last chapter, render
a knowledge of the various sexual anomalies an essential part of
the mental equipment of every medical man, quite apart from the
fact that he may occasionally be consulted about such matters
directly. For, on the one hand, he will be unable without such
knowledge to discern the symbolic meaning of the behaviour of
his patients and, on the other, the time has come when these
perversions must be faced as psychological, psychiatrical, or even
everyday practical problems rather than shunned as loathsome
vices outside the realm of legitimate medicine.
The whole purport of evolution is perfection of the organism
for these two functions:—preservation of the individual and
reproduction of the species. All else is subsidiary to these.
The pristine significance of the sexual act, by which reproduc-
tion is effected, renders the study of its anomalies indispensable
and their unesthetic, revolting, disgusting and criminal character
does not justify their neglect any more than the loathsomeness
of a physical disease would exonerate a medical man from dealing
with it.
In such a manual as the present, however, it is only possible
to mention briefly the various anomalies of the sexual instinct.
Readers desirous of making a more complete study of the subject
should consult one of the numerous monographs, of which “ The
Psychology of Sex ’’, by Havelock Ellis, is the most masterly.
Many of these perversions are extremely common. Some
authorities, for example, go so far as to suspect over go per cent.
of the adult population of having been addicted to masturbation
at some time in their lives. This habit may arise either from
circumstances being adverse to normal gratification of the sexual
instinct or from repugnance against the normal sexual act
(frigidity). In the latter case the victim (taking the male as a
paradigm) has never escaped from his infantile identification
with his mother and, in his revolt against the idea of regarding
himself as a female and seeking conjugal relations with members
Ig!
192 MIND AND ITS DISORDERS
of his own sex, his affection is turned towards himself (narcissism)
and he commits what is really a homosexual act (loving a person
of the same sex), which in such guise is unconsciously regarded
as permissible.
Masturbation is popularly supposed to be a vice more destruc-
tive to health than any other and a certain cause of insanity;
but this notion is erroneous. Masturbation fer se is harmless.
Psychical auto-erotism or narcissism plays an undoubted réle
in the genesis of some neuroses (especially neurasthenia) and
psychoses, as also does the worry the victim suffers from his
inability to renounce a practice which he supposes to be harm-
ful, a worry consisting of a conflict between the impulse of the
unconscious to masturbate and the conscious desire not to do so;
but the physical act itself does no harm whatever, and victims
are more readily cured by telling them this than by holding up
to them the bogey of insanity, as many physicians do.
Sexual Inversion or Homosexuality is that condition in which
a person is attracted towards members of his own sex and has no
desire towards the opposite sex. It is extraordinarily common,
being admitted by about 5 per cent. of males and ro per cent. of
females. Some of these indulge in coarse homosexual practices
known as “ sodomy ”’ or “‘ pederasty ’’ in males and as “ Lesbian
love ’’, “‘sapphism”’ or “ tribadism ”’ in females. Such practices
are varieties of mutual sexual gratification.
To most people homosexual thoughts are naturally repugnant,
and so it happens that there are many homosexuals, not included
in the above 5 and Io per cent., who are unwilling to admit this
peculiarity to themselves. The desire is repressed and they do
not know—consciously—that they are inverts; so much so that
they may even marry and beget children. Such unconscious
inversion is liable to express itself in symptomatic form, and
thus give rise to psychosis. At least one author goes so far as to
state that all psychotics are repressed homosexuals. This is not
true, but it is not far from being true. Intrapsychic conflict arises
primarily from a reaction against the unconscious homosexual
tendency, which reaction causes the patient consciously to dislike
members of his or her own sex to an unusual degree, although the
unconscious is particularly interested in them.
A normal person is heterosexual, but not entirely so. Hetero-
sexuality is not as a rule so strong that he or she is devoid of
friendly feelings toward members of his or her own sex, but this
sometimes occurs.
Just as some people are so right-handed that their left hand is
HOMOSEXUALITY 193
practically useless to them and some so left-handed that their
right hand is practically useless, while most are rather more
right-handed than left-handed, some slightly more left-handed
than right-handed, and others again (a very small group) strictly
ambidextrous; so some people are so heterosexual that any
member of the same sex is obnoxious to them and some so homo-
sexual that any member of the opposite sex is obnoxious, while
most are rather more heterosexual than homosexual, some
slightly more homosexual than heterosexual, and others again
(a very small group) strictly ambivalent. I am referring to un-
conscious tendencies; the conscious mind would, of course, deviate
an ambivalent person towards heterosexuality.
Psycho-analysis has revealed that the heterosexual or homo-
sexual tendency is directly traceable to the way in which the
subject regards his own father and mother (or their surrogates).
If the home conditions are such as to cause a child to feel ab-
normally and persistently dependent upon and thus, or in some
other manner, to identify himself or herself with the parent of the
opposite sex, he or she becomes a homosexual; and since the home
conditions are usually similar for all the members of a family, it
is not uncommon to find that homosexuality is hable to run in
families, all or most of the sons or daughters being affected, very
seldom both. For example, the sons of an eccentric father and
the daughters of an eccentric mother are liable to become homo-
sexuals, or neuropaths owing to repressed homosexuality. This
fact explains the exaggerated importance which has hitherto been
attributed to heredity as an etiological factor of insanity; there
are other ways than heredity in which the father and mother can
influence the life of their children. The importance of this sub-
ject can scarcely be overestimated, for it has a bearing on many
problems of the day—education, for example.
In the above remarks, homosexuality has been utilized as a
paradigm on account of its frequency; but there are many other
sexual abnormalities whose repression may result in symptom
formation.
In the cases above mentioned, the patient possesses psychical,
and often physical, characteristics of the opposite sex and their
desire is usually towards members of their own sex. Sometimes,
however, we find on psycho-analysis that such persons have
desire towards members of the opposite sex, so that they are,
in a way, doubly homosexual; for mentally they are of the
opposite sex and also have desire towards the opposite sex—
mentally the same sex as themselves, Such individuals often
13
I94 MIND AND ITS DISORDERS
make a happy marriage, although homosexuality usually leads
to unhappiness in married life.
There is yet another class:—people whose mentality and
physique are strongly characteristic of their own sex, yet whose
desire is towards members of their own sex—preferably those
who resemble in some way members of the opposite sex, for
example—very masculine men who seek sexual gratification with
boys (the Oscar Wilde type). This is really a variety of the
obsessional neurosis and can sometimes be cured by psycho-
analysis.
The first variety is incurable; psycho-analysis can no more
render such people heterosexual than it could hope to make
heterosexual people homosexual.
Sadism and Masochism (active and passive algolagnia), which
appear to be extraordinarily widespread, belong to an entirely
different category.
A sadist is a person whose sexual instinct is stimulated and
gratified by inflicting pain, cruelty or degradation on others.
Whipping is the prototype of such humiliations and it may
suffice to see the pain inflicted by another person, to hear the
cries of the victim, or even to hear or read some story of torture.
There is an infinite variety of methods of inflicting pain which
appeal to sadists, not excluding murder. The Whitechapel
murders by “ Jack the Ripper’ in the last century were a
typical example of sadism. It is not necessary that the victim
should be a woman or even a human being. Bloch relates the
case of a man who used to kill a hen at every sexual debauch.
Some instances of the violation of female children should probably
be classified in this category. Theft sometimes occurs as a
sadistic act. The infliction of pain is the chief pleasure to some
sadists, while others are more gratified by the helplessness of the
victim or by his degradation.
A masochist is a person who seeks and submits to pain, torture
or degradation, sometimes of the most disgusting character, in
order to stimulate and gratify his sexual instinct. He loves to
be bound and scourged with rods and whips, perhaps till blood
flows, or to be treated as a slave or a dog—e.g., to lie at his
mistress’s feet and have bones thrown to him, or, at least, to
imagine himself in such situations. Many women wear painfully
tight shoes, corsets or gloves for the sake of the sensual effect
produced by such articles of clothing.
Masochism and sadism are vindicated on the ground that their
occurrence in one form or another is quite common throughout
SADISM AND MASOCHISM I9Q5
the Animal Kingdom. The cock uses his spurs on the hen, cats
bite and scratch their females during coitus and stags beat their
does with their horns in courtship. .
In man the sadistic tendency is born of a special aggressiveness
in childhood, which takes the form of an intensive desire to learn
about sexual matters and the mystery of birth by gazing and
peeping on the one hand and by aggressive questioning on the
other. This interest is usually aroused by parental indiscretions
in the presence of the child, witnessing coitus between animals
and such-like. The latter is indeed generally regarded by children
as a combat.
Masochism similarly dates from the infantile period when a
child loves to expose its own body. In adult life such an action
would assuredly symbolize submission. Indeed it is something
more than symbolism when in tender years an intimate part of the
body is exposed in order to receive punishment by the infliction
of pain.
Sadism and masochism usually occur together in the same
individual, one or the other preponderating. Dr. Ernest Jones
has traced their deeper origin to repressed anal erotism in most
cases, while in others Abrahams has traced them to repressed
oral eroetism. They are not due, as is popularly supposed, to
corporal punishment received in childhood. Sado-masochism is
a perversion in which the subject obtains sexual gratification by
inflicting pain of some sort on himself.
The above-mentioned tendency to gaze and peep at objects of
sexual interest sometimes persists into adult life, the victims
being generally known as “‘voyeurs’’ or peepers (scoptophilia).
The infantile tendency to expose the body to the public gaze
finds an annual outlet at the seaside; but some, usually males,
find pleasure in bizarre exposure of the genitalia. Such are
known as “‘ exhibitionists’”’. This peculiarity possesses a sadistic
element in the desire to give offence to others and a masochistic
element in the wish to obtain a bad reputation. Like active
and passive algolagnia, scoptophilia (pleasure of looking) and
exhibitionism are usually combined in the same individual, one
or the other preponderating.
When algolagnia is repressed it usually finds expression in one
or more of the various symptoms of the compulsion neurosis
hereinafter described. Self-punishment is also the root of many
hysterical symptoms and of melancholia.
The Role of the Senses.—Normally, attraction to the opposite
sex is stimulated by an appeal to the senses, The fouch of a
196 MIND AND ITS DISORDERS
loved one in any part of the body is a stimulus to the sexual
instinct. Kissing, apposition of the breasts and congress of the
external genitalia in the embrace of opposite sexes are to be
regarded as normal; but perversions occur in the form of fellatio
(apposition of the male genital organ to the mouth of another
person) and cunnilingus (apposition between female genitalia
and the mouth of another person). In some cases the anal canal
is made to do service for the female genitalia, even between
husband and wife, the sexual orgasm being thus aroused in both
parties (sodomy).
Sexual desire is stimulated in some persons by touching fur,
velvet or some other material or object used in female attire.
When this-peculiarity is so magnified as to be effective by itself
it is known as fetichism.
Viston normally plays an important rdle. A beautiful face,
a full bust, a well-developed gluteal region, a delicate hand or
a pretty foot appeal to men in varying degrees; similarly height,
muscularity and apparent strength, a hirsute face or a bass voice
in a man may appeal to a woman; but when female character-
istics in a man or male characteristics in a woman attract a
member of the opposite sex, such as a contralto or tenor voice,
this is strongly suggestive of homosexuality, either latent or
acknowledged. A curious transfer of the affect takes place in
certain individuals who attach undue importance to clothing
so that gloves are more effective than hands, corsets more than
figures and shoes more than feet. This is another variety of
fetichism. Underclothing, garters, stockings and handkerchiefs
also commonly serve as fetiches. Women’s hair, too, is often a
fetich, to such an extent in some men that they will seek oppor-
tunity to cut off whole plaits or large-portions of the tresses of
their victims with scissors. Wig-collectors are less objectionable
hair fetichists.
Smell appears to play a large part in the sexual life of some
persons. There are many distinctive odours about a woman:
the hair, the sweat, the warm breath extolled by some novelists,
the axille, the breasts (especially during lactation), the perineum
(especially during menstruation) and the feet, as well as a
combined odour of the whole individual. All of these have
their devotees, whose predilections may induce them to steal
ladies’ handkerchiefs or, if possible, articles of underclothing.
In this connection the use of artificial scents for purposes of
sexual allurement will naturally occur to the reader.
Taste probably plays no part in sexual life and hearing very
SEXUAL ABNORMALITIES 197
little, but the sound of a voice or of the rustling of female clothing
is sometimes effective as a fetich.
Bestiality (connection with animals), occurring in both sexes,
and necrophilia (violation of corpses), a vice limited to males,
may also arise as a result of circumstances; but there are indi-
viduals who indulge in such depravities from choice.
Pygmalionism may here be mentioned, a curious perversion
whose subjects are liable to fall in love with statues. They
sometimes masturbate before statues, even of the Virgin Mary.
The victims of fetichism, bestiality and pygmalionism some-
times refuse to admit to themselves that such peculiarities form
any part of their psychology, and they thereby repress them
into their unconscious. The strife of such tendencies for recog-
nition under such circumstances may give rise to symptoms,
usually of a compulsive or obsessive nature; but I have also
come across them (repressed) in several hysterical patients.
Sexual perversion in itself, especially sexual inversion, can
scarcely be regarded as a sign of degeneracy, for it claims among
its victims men of the highest rank and intelligence. It is re-
pression of the perversion that is dangerous to mentation. On
the other hand, there are many cases of insanity in which some
sexual perversion, such as znucest or clamour for free love, which
has not hitherto been mentioned, has occurred as a symptom,
and many more cases in which some perverted sexual incident
has served as a factor in the patient’s malady. The perversions
discussed in this chapter are not by any means all that exist,
and in psycho-analytical investigation we hear of many more
phantastic repressed sexual perversions, which probably never
occur in actual life, some being physically impossible of per-
formance. .
The treatment of manifest sexual perversion is often very
difficult. The practitioner must be warned to be very cautious
in advising marriage to sexual perverts, and it should never
be advised to sexual inverts in the hope that heterosexuality
will develop.
PAIR Site
MENTAL DISEASES.
CHABTERSIE
THE CAUSATION OF MENTAL DISORDER.
THE specific causes of the various psychical disorders will be
discussed in the ensuing chapters, separately devoted to indi-
vidual mental maladies; but it will be helpful to take a broad
preliminary survey of the etiology of mental disorder in general.
The first part of this manual comprises an account of physio-
logical psychology, which derives all psychical processes from
sensation. The principles there enunciated are scientifically
accurate and they provide us with a serviceable classification of
mental mechanisms, upon which we can base our description of
symptomatic deviations from the normal, but it must be ad-
mitted that this laboratory psychology has contributed practi-
cally nothing to our discernment of the fundamental nature of
diseases of the mind, because laboratory psychology is rather out
of touch with the psychology of everyday life.
Modern psycho-analytical psychology, on the other hand, has
taught us that, for practical purposes, the core of our daily
mental life is not sensation, but desive. Our mental life consists
of a constant endeavour to do what we want to do, to gratify
our desires, to fulfil our wishes. Yet psycho-analysis has
revealed another important truth, that many of our desires are
unknown to ourselves, unconscious and even in direct antagonism
to our conscious wishes.
This state of affairs naturally gives rise to intrapsychic con-
flict; but such conflict is usually avoided, as we have seen, by
sublimation, whereby the gratification of an unconscious wish is
achieved in a disguise acceptable to conscious thought. When,
from any cause, sublimation fails and an unconscious wish
threatens to assert itself in consciousness undisguised, the result
is intrapsychic conflict, an unbearable situation which is avoided
by flight into some mental disorder which is more tolerable or,
198
HEREDITARY INFLUENCE 199
at least, the best way out of the difficulty. In this sense mental
disease is nothing more or less than an adjustment of the per-
sonality. In some cases the manifestations of the malady may
be physical (hysterical paralysis and “ functional’’ tachycardia,
for example), but we must never lose sight of the fact that such
maladies are of mental origin; in fact, we now know that the
time-honoured epithet ‘“‘functional’’ means “‘ psychical ’’—
nothing more or less.
The neuroses, psychoneuroses and biogenetic psychoses originate
from this intrapsychic conflict alone; but there are other mental
diseases whose psychical manifestations bear a remarkable
resemblance to these, but whose incidence is clearly traceable
to physical causes—for example, alcoholic intoxication, fever
delirium and organic brain disease, such as general paralysis.
In such conditions, however, the mental symptoms are due to
intrapsychic conflict in exactly the same way; they differ merely
in the fact that the failure of sublimation or repression is due,
not to the abnormal strength of the complex which causes it to
burst its bonds, but to the organic affection of the brain weakening
the repressing forces.
In the chapters on the emotions and instincts it was pointed out
that organic disease affects the more recently evolved volitional
system more than the pristine instinctive system and tends to
let loose the activities of the latter, and it is not assuming too
much to say that the volitional system is the physical basis of
conscious and preconscious repressing forces. The effect of
organic affections of the brain is therefore to weaken the repressing
forces, so that complexes, which would otherwise have remained
repressed, are allowed to battle on equal terms with the repress-
ing forces, the result of such conflict being mental disorder
resembling that of the biogenetic psychoses or neuroses.
The recognition that intrapsychic conflict is the fundamental
cause and essence of all mental disorders, whether functional or
organic in origin, must be taken into account in considering all
other etiological factors. |
If, for example, there is anything in the old doctrine that
heredity is responsible for nearly 50 per cent. of all cases of
insanity, we would have to suppose that nearly 50 per cent. of
the insane are born with an inherently defective volitional
system, implying inherently weak repressing forces, which (in
the light of our present knowledge) seems rather absurd; but,
as a matter of fact, we are now realizing more and more that
200 MIND AND ITS DISORDERS
there are other ways than heredity by which a person may be
influenced to his detriment by other members of the family who
come into frequent contact with him in his earliest years, especi-
ally the parents. Eccentricity or other mental abnormality of
the father is especially liable to affect the daughters, while
peculiarities of the mother are apt to work upon the sons by
directing the childish libido to the parent of the same sex and
thus tending to induce a homosexual tendency, which may be
repressed in later life and then be forced to find expression in
psychotic symptoms.
Such considerations have to be taken into account in consider-
ing all statistics hitherto published, which bear on the subject
of heredity in mental disease, and perhaps render them valueless;
but, to be fair, it ought to be mentioned that Rosanoff and Orr,
from the study of 72 families, representing 206 marriages with
a total of 1,097 descendants, came to the conclusion that neuro-
pathic heredity follows the Mendelian law, assuming normality
to be “dominant ’”’ and “‘ neuropathy’’ to be “ recessive’. I
have not studied their paper with sufficient care to satisfy myself
whether I consider their conclusion to be justified or not.
With a view to determining the importance of heredity as an
etiological factor of insanity, Otto Diem of Herisau compared
the parentage of 370 sane and 370 insane people, with the follow-
ing results:
Parents of | Parents of
370 Sane. | 370 Insane.
Insanity ar on a ae ao 17 68
Alcoholism ie o — = v7 32 63
Senile dementia oe = 45 ue I 10
Eccentricity afi rv ~ ae the 22 67
Suicide a ay Ms a cis 2 4
Total abnormal oA ie a ele 74 212
Total normal me Bd me ah 666 528
Total of all parents .. he <a s 740 740
Hereditary influence is said to be direct when the father or
mother of the patient has suffered from mental disease; but this
is of no importance, for it is now recognized that the parents
contribute nothing to their offspring but their ova and sper-
matozoa, which originate from cells specially set apart for the
HEREDITARY INFLUENCE 201
purpose of reproduction during the early stages of their own
foetal life. This doctrine is known as the “continuity of the
germ-plasm ’’; but it accepts, of course, the fact that the fertilized
ovum is nourished by the maternal blood.
Heredity is said to be collateral when mental disease occurs
only among the brothers, sisters, uncles, aunts or cousins of
the patient.
When any of the grandparents or more remote ancestors, but
not the parents of the patient, have been mentally afflicted the
hereditary influence is said to be atavistic. We need not nowa-
days discuss how many generations are necessary to exhaust the
influence of atavistic heredity, for Lombroso and Lacassaigne long
ago suggested that the brutality of certain criminals is atavistic,
dating from their ancestry in the wilds of the forest, and we now
know that the basest animal instincts exist in the unconscious
of every one of us. Fortunately they usually find expression
through sublimation into useful activities.
There is an ill-founded popular notion that the children of
parents related to one another show a special predisposition to
insanity. If a neuropathic tendency has already shown itself in
the ancestry of such parents their union in wedlock renders the
evil hereditary influence cumulative; but if those parents come
of a healthy stock their offspring will not only be free from any
tendency to disease, they will have the advantage of cumulative
tendencies to health. _
The various members of some neuropathic families tend to
develop the same type of nervous disease; in these cases, the
hereditary influence is said to be s¢milay and the family charac-
teristic may prove helpful in framing a diagnosis and prognosis.
In other cases the family shows a general neuropathic tendency
to develop heterogeneous affections of the nervous system bearing
little resemblance to the diseases of the ancestors; the hereditary
influence is then said to be dissimilar. Some patients not only
develop the family disease, but do so at the same age as other
affected members of the family. More commonly, however, we
find that nervous disease tends to appear at an earlier age in
the children than in the parents.
From observations on my own patients I am inclined to the
opinion that the proportion of cases of “‘ similar heredity ”’ is
much larger than is usually believed and that the distinction
between similar and dissimilar heredity is therefore justifiable.
Mott, on the other hand, is of the opinion that the type of mental
disorder in a family tends to become more and more degenerate,
202 MIND AND ITS DISORDERS
maniacal-depressives begetting dementia preecox, and _ this
begetting idiocy for example, so that the degenerate stock is
brought to an end.
Although marriage with a psychotic individual is usually in-
advisable on personal grounds, the view is generally held that it
is quite possible to regenerate a degenerate stock by suitable
matings with healthy individuals, and the latest eugenic idea
is that the choice of a mate for a psychotic person, or even for a
healthy person, should be State controlled. This nation has
recently seen enough of State control to teach it that those who
contemplate extending this principle do not understand human
psychology. Similarly, the oft-suggested sterilization of the
insane is not only antisocial interference, but it is totally un-
warranted by our knowledge of the causation of mental disease.
From the accompanying tables, taken from the Commis-
sioners’ Report for 1903, and from the chart which I have con-
structed from Table III., many lessons may be learned with
regard to the relationship of age, sex and civil state to the
incidence of insanity.
It will be seen that insanity is at least twice as common in
the single as in the married. That this fact is not due to any
avoidance of marriage on the part of the neuropaths is shown
by the frequency of mental disease among the widowed; insanity
appears to be directly caused by the evil influence of a single life
and by enforced repression of the sexual instincts and complexes.
It is, in fact, now definitely established that the anxiety neurosis
and some cases of anxiety hysteria are induced by sexual excita-
tion without gratification. A further explanation of the high
incidence of mental disease in the unmarried is that married
life does not appeal to those who are sexually perverted and
therefore remain single. If the sexual perversion is repressed —
they are unconscious of the real reason why they remain single
and, on the other hand, their perversion is liable to find expression
in psychotic symptoms.
The curve for the married men shows little more than an
increasing tendency to insanity as age advances; there is a slight
rise in the curve at middle life, probably due to the incidence
of general paralysis during that period. During the child-
bearing period insanity is more common in married women than
in married men. . In all other instances, insanity is proportion-
ately more frequent in men than in women. This appears at
first sight to be rather surprising in view of the fact that homo-
sexuality is much more frequent in women than in men; but the
tE CENSUS OQ
f the Census
|
Total.
3 688,469
3 3,117,2591,1
[| 190,277
1 ‘‘ widowed,”’
age; and that
sons were adn
TABLE I.
SHOWING THE AGES or ALL PERsons IN ENGLAND AND WALES AT THE TIME OF THE CENSUS OF I901, WITH THEIR CONDITION AS TO MARRIAGE.
(Taken from Table XXIX. of the Summary Tables of the Census of April 1st, 1901.)
| Total.
Under 15. I5—1I09. 20—2 aa" a se BGS 64, 65 and upwards.
Condition 2 Se | at 22 d 25—34 5 =D 44 45—54 :
= | | | | | | | Total Mal Females Total.
Marriage. Males. | Females.| Total. | Males. | Females. | Total. Males. | Females.| Total. | Males. | Females.| Total. | Males. Females. Total. | Males. | Females.| Total. | Males. | Females., Total. | Males. | Females. otal. ales. :
—— | | | | | | | | | ee a ees
: l | ee ae eee ee eee ee ee ty [poe ae me | 88
— 5,265,324 5,280,415 10,545, 739|1,603,066|1,613,138 3,216,204 1,216 628 1,196,555 2,413,183 892,226 941,161/1,833,387| 306,001] 382,468 688,469] 154,118 205,176 359,294; 80,494 | 121,038) 201,532| 49,045| 95,335| 144,380 See ea oer
eo Sf wa 4423) 25,392) 29815) 254,169 447,885 702,054 T, 569,094 1,781,022) 3,350,116|1,567,616|1, 549,643 3,117,259/1,143,059 1,061,938, 2,204,997] 693,550 | 589,380/1,282,930/379,470 | 262,277 | ceig! 5, ae z med coe coe Poe
idowed SS == — aS “QI| 124| 1,847 3,838, 5,085 24,024| a7, 703 | — 72,437) — 58,320 131,95%, 190,277] 99,032) 238,868 337,900] 133,901 | 324,887, 458,788/323,557| 499,069 | 731,62 55 iso 2 Seas
———S —— : | i ) | es Se
Total 5,205,324 5,280,415 10,545,739|1,607,522|1,638,621 3,246,143 1,472,044 TOsS e981 sac92 2,485,954 2,709,886) 5,255,840 1,931,943 2,064,062 3,996,005 T; 39,209) 1,505,982)2,902;191 907,945 1,035,305,1,943,250/661,072 | 856,681 I,517,753\||15,729,6013 | 16,799,230 32,527,843
| | | | |
TABLESIL:
SHOWING THE YEARLY AVERAGE OF THE NUMBER OF PATIENTS ADMITTED INTO COUNTY AND Boroucu AsyLums, RecIsTERED Hospirars, NAVAL AND Mititary Hospirars, State ASYLUMS AND LicENSED Houses IN ENGLAND AND WALES
DURING THE FIVE YEARS 1898 To 1902 INCLUSIVE, WITH THEIR AGES AND CONDITION AS TO MARRIAGE.
|
Under 15. [5—10. 20—24. 25a et sae Aaa4s 65 and upwards. | Total. =
Condition ———____— = ee a Se ee ee = =. AS i i —
as to | | | | | l Total
Marriage. Males. Females. Total. | Males. | Females.| Total. | Males. | Females.| Total. | Males | Females.| Total. | Males. | Females.| Total. | Males. Females., Total. | Males. | Females. Total. | Males. | Females.| Total. Males. | Females. otal.
Single 151 103 254 | 466 432 808 866 | 752 1,618 1.495 1,202 2,697 | 802 812 1,615 306 502 898 = 196 246 442 | 109 185 | 2904 || 4,482 | 4,234 8,715
Married = = a — I Io II 41 LO3— 4} - 234 659 1,077 1,736 1,34 9=+|\--1. 206 2,632 1,105 1092 ei oe. 726 544 1270 472 263 TaD 4,345 | 4,409 | 8,754
Widowed —= i ae — — -- I al 4 2 46 71 104 192 206 179 344 | 523 225 407 ee | Santer | 660 1,052 926 | 1,651 Petre 0
Unknown = — | — 2 == = 2 2 4 16 5 2Y 29 8 37 20 9 | 29 12 3 15 | 10 3 13 go 30° | 120
\ | | |
Bias ees ee Cl oe ey 467 442 go09 O10 meOe0 1,859 | 2,195 25330 |. 4,525.1 2.278) 2 401 4.570. 1,700 1,887 | 37587 1,159 I,200 2,359 | 984 Tamar 2,095 | 9,843 10,324 20,167
TABLE-1Uie
SHOWING THE RATIO (PER 10,000) OF THE YEARLY AVERAGE NUMBER OF PATIENTS ADMITTED INTO CoUNTY AND BoroucH AsyLuMs, REGISTERED Hospitats, NavaL AND Mititary Hospirats, STATE ASYLUMS AND LICENSED HousEs IN ENGLAND AND WALES
DURING THE FIVE YEARS 1898 TO 1902 INCLUSIVE, TO THE GENERAL POPULATION (AT THE TIME OF THE CENSUS OF I901), ARRANGED ACCORDING TO THEIR AGES AND CONDITION AS TO*MARRIAGE.
Under 15. I5—I9Q. 20—24. 25—34. 35—44. | 45—54. 55—64. 65 and upwards. Total.
Condition = = ee el a ————SS - —— - ——— eee ~ = - —ar er == =
as to | | | | | | | | | | |
Marriage. Males. | Females. Total. Males... Females. Total. | Males. | Females.; Total. | Males. Females. Total. | Males. | Females. Total. | Males. | Females.| Total. | Males. | Females. Total. | Males.| Females. Total. | Males. Females. Total.
| | | | | = | He Bs
|
Single 0°3 O°2 0-2 20a ge 225 Vik toe im Se 6°7 16°8 12°) 14°7 26°2 22 23°51 2520 24°5 25°O 24°3 20° 21°9 Pe Mages = Seo | 20°4 || 4°7 4°3 4°5
Married — == -— PIE as ean 6 51 Eo Rome 6, 4°3 303 4°2 6:0 5°2 8-6 8-3 8°4 9°7 0°7 0°7 10'5 g°2 9°9 T2°4 |b Toso II*5 77 7°7 ae
Widowed —- — = — = — 5°4 7°8 7:0 IOrL 9°6 9°8 17°8 14°6 15°60 IS‘ TA ee eine 16:8 1225 salam Tes 169 eee 144 | 16°8 Ess2 14°3
|
| |
Total 0°3 Or2 0-2 2°9 207 2° Sete 6°2 | 5°8 6:0 Sl ees a) ie carcass CT 11°8 nie ig 12°20) 125 | 124 12°8 Tr6 P207 14°9 I3°0 1 ee. 6°3 | 6°1 Gaz
| | | |
Note.—It will be observed that in nearly all the above periods the proportions of the “ single ”’ considerably exceed those of the ‘“‘married’”’ and “widowed,’’ while in the total of all ages these ratios are reversed. This is due to the facts
population under twenty years of age were “‘ single’; that three-quarters of the “ single’’ population were composed of persons under twenty years ofage; and that the numbers of patients
The above table shows that, at the marriageable ages, and in proportion to the general population, considerably more single than married or widowed persons were admitted.
that nearly all the persons in the
under that age who were admitted into asylums, etc., during the five years were relatively few.
(To face p. 202.
THE LIPRARY
OF THE
UNIVERSITY OF ILLINOIS
Ratto Age
Per 10,000
35-44
45-54
55- 64
65 glipwoa rds
g a + +
of Sane Bm ah
Population | " 6 4
atsameage)} 3S ~ NS
es |e a i
tt
aia
Ras
BRAS
Sa
me
|
SPITS
Saas
ee
Seat /2sam
ERR VME
| et a ae
2a ees saa
| ae FL a
Ue] pees] Sea a a
ARSE LMSC
Ff
aff
4
3
2
7
0
Insane Bachelors
" Spinsters
sda ane a pe Widowers
» +Widours
oy eer : Married Men
. Women
Fic. 25.—INCIDENCE OF INSANITY IN RELATION TO MARRIAGE.
To face p. 203
ETIOLOGY OF INSANITY 203
incongruity is easily explained by the fact that homosexuality
can be more easily sublimated in women, into intimate friend-
ships, for example, which are more tolerated between women than
between men. The legitimate spheres of activity for women
also afford more suitable outlets for the complex.
On the other hand, the female insane population exceeds the
male insane population, both absolutely and relatively, 35:77 per
10,000 of the male population being certified as insane, as against
39°12 of the female.* This discrepancy may almost entirely
be accounted for by deaths from general paralysis, since (when
these statistics were compiled) 1,100 men died annually in
England and Wales of that disease, but only 300 women.
Before or during menstruation women are liable to exacer-
bation of their mental symptoms because sexual desire is strongest
at these times and therefore tends to escape repression and,
during the menopause when there is also an augmentation of
the sexual instinct, there is an increased liability to develop
mental disorder of some kind.
The gradually increasing tendency to mental disease as age
advances is probably to be explained by the fact that the uncon-
- scious is constantly growing at the expense of the conscious.
The unconscious of an old man is therefore much more volu-
minous, so to speak, than it was when he was yet young. More-
over, the abiotrophic tendencies of senility would make for
weakening of the repressing forces.
The exogenous causes of insanity are either mental or physical.
Worry of various kinds is the most frequently ascribed mental
cause of an attack; but it is commonly found, on probing the
matter, that worry, which is nothing more than “ meeting
troubles half way ’’, was only the first symptom, not the real
cause. However, there is not the shghtest doubt that the onset
of many attacks of insanity is determined by the “ loss of rela-
tives and friends’’, ‘“‘ business anxieties and pecuniary diffi-
culties’”’. Still, it is doubtful whether such causes are as frequent
as the statistics of the Board of Control represent them to be.
In cases which have been ascribed to business worries or pecuniary
difficulties we often find on inquiry that the patient’s affairs are
fairly satisfactory and that the sole cause of the worry is his
inability to appreciate his true financial position. When a
person becomes depressed he worries over trifles, even imaginary
ones.
“Fright and other forms of nervous shock”’ are said to be
* Figures based on the insane population of 1906 and the census of 1901.
204 MIND AND ITS DISORDERS
responsible for more than 1 per cent. (according to the statistics
of the Board of Control) of the admissions to asylums; but here
again we must be on our guard and recognize that, of all the
people exposed to such influences, a certain number are already
on the verge of a nervous breakdown. Cases undoubtedly occur
which are directly traceable to such incidents as seeing a friend
killed or waking to find a bedfellow dead. Acute confusional
insanity is the usual result. Love-affairs, on the other hand,
more frequently lead to maniacal excitement; acute delirious
mania sometimes occurs in such cases, so that the novelist is
right when he makes his jilted heroine die within a few weeks
from the excitement of “ brain fever’’. These cases supply a
severe criticism of the view, which some doctors tend to push
to its utmost limits, that insanity is always due to a toxin cir-
culating in the blood.*
A person with unsublimated complexes is liable to an attack
of insanity at any time and under any circumstances; hence it
has happened that almost every circumstance under the sun
has been labelled the cause of insanity. A man’s religion,
his education, his profession and nationality have all been
blamed.
Religion acts in all sorts of ways. In the first place, it must
not be forgotten that all religions descend from a primitive
phallic worship and have many sexual symbolisms in their rites.
The unconscious knows the meaning of such symbols, but the
conscious does not, and the rupture of this barrier between the
two may give rise to mental symptoms. Secondly, the aim of
most religious teaching is to repress the animal instincts, to
“subdue the flesh’’, often to a degree which is dangerous to
mentation. The frequency of psychical maladies among the
orthodox Jews is dependent upon the very repressing influence
of their religion and especially the great importance they attach
to the Fifth Commandment, which fixates the father and mother
complexes without revealing them to consciousness in their true
light. A propos the Church of England, Samuel Butler in
“The Way of All Flesh”’ tritely opines that there could have
been no child member of the Committee that drew up the
Catechism. Such religions as theosophy and _ spiritualism
encourage the formation of hallucinations and contribute a
relatively large number of obstinately incurable patients to the
neurotic population; but in fairness to such doctrines it must
* IT have known many cases, with purely psychotic manifestations,
unjustifiably treated with vaccines.
ETIOLOGY OF INSANITY 205
be acknowledged that their form of mysticism or occultism
appears to be particularly attractive to neuropaths, and their
adherence to this variety of religion may well be regarded as
a symptom rather than a cause. Many who lost their dear
ones in the War became converted to spiritualism because it
fulfilled their unconscious wish to be able to communicate with
the dead. Roman Catholicism is apparently a very satisfying
religion because this Church plays the role of Mother to its
adherents, and the impression I have acquired, from rather
extensive experience, is that Roman Catholics are rather less
liable to mental disease than members of other religions. Delu-
sions of wickedness and consequent perdition are rare among
Roman Catholics. On the other hand, changing from a less
to a more ritualistic form of religion, e.g., from Nonconformity
to Church of England and from Church of England to Roman
Catholicism is frequently, for some obscure reason, a psychotic
manifestation of evil prognostic significance.
Of late years an assumed over-education has been advanced
as a cause of insanity. The notion is obviously erroneous.
Everybody is more or less educated; but, so far as I am aware,
there are no statistics to show that insanity is unusually preva-
lent among the educated classes. The authorities at idiot
establishments recognize that judicious education has a bene-
ficial rather than a deleterious influence on their patients. A
badly-conducted education is of course harmful and children
that have been “ spoiled’”’ are apt to find themselves unfitted
for the world they have to live in. ‘“‘Only”’ children and
“ favourite ’’ children are generally ill-fitted for the world they
live in and zfso facto specially liable to psychosis or neurosis.
Moreover, education has hitherto been of too repressing a
character, especially in relation to sexual matters. The child
receives no education respecting its own instincts and is even
forbidden to ask about them, so that its conscious thought is
early brought into conflict with its inborn trends.
Mental disease is especially frequent in those professions which
entail a large amount of worry; but the worry, not the pro-
fession, should in these cases be held responsible for the disorder.
It frequently happens that persons of an artistic temperament
are of an unstable nervous constitution; consequently artists,
musicians and poets are exceptionally liable to insanity. The
reason for this lies in the fact that Art serves the purpose of very
successfully sublimating several sexual perversions, notably
homosexuality and anal erotism. When Art fails to fulfil this
206 MIND AND ITS DISORDERS
function, intrapsychic conflict results which necessitates flight
into psychosis.
The incidence of insanity among the several nationalities
forms an interesting chapter in the etiology of insanity. It is
difficult to make satisfactory comparisons because provision
for the insane varies widely in different countries, and the causes
of insanity in one country may be non-existent in another.
For example, pellagrous insanity is a common disease in Northern
Italy, but is almost unknown in this country; and hashish
insanity, while unknown in the West, is common in the East.
In comparing the different nationalities of the world we find
that insanity is essentially a disease of modern civilization and
that it is most frequent in those countries where civilization
has made the greatest advances. Mental disorder is not un-
known among savages, but it is comparatively rare. In almost
all the textbooks of insanity this effect of civilization is ascribed
to hurry and bustle and to the struggle for existence among
civilized people, especially among urban communities, on the
erroneous supposition that insanity is relatively more common
in the large cities. Popular lecturers advertise that insanity
and other diseases are due to defective sanitation, insufficient
sleep, overwork, poverty, the noise of the streets at night, brain-
fag, and, as we have just seen, education.
Now this is manifestly erroneous. Even its premises are false.
How can anybody bring himself to believe that defective sani-
tation is a cause of the degeneration of civilized communities,
when he compares the magnificent systems of sanitation in our
great cities with their complete absence among savage races,
among whom degeneration does not occur ?
Mental disorder can scarcely be said to be common in brain-
workers and it is certainly very rare in children under educa-
tion. Overwork, too, is somewhat of a myth. It is true that
we get through a tremendous amount of work nowadays, but
this is merely because work is rendered easier by modern scientific
instruments and labour-saving appliances; and, as regards this
fierce struggle for existence, we do not know what it is, compared
with the conditions of existence among primitive peoples. Is
a savage in debt to his fellows ? His goods are confiscated and
he is probably killed, perhaps to make a meal for his creditors.
Is he sick of a disease ? He is carried into the wilds of the forest
and left there to die. Is he suicidal? The means are placed at
his disposal that he may kill himself withal. Is he subject to
attacks of frenzy which render him a source of annoyance to his
SURVIVAL OF THE UNFITTEST 207
fellows? They fall upon him and slay him. Thus do primitive
nations free their country of undesirables.
Compare this condition of affairs with that of a civilized com-
munity. The bankrupt is allowed to pay his creditors sixpence
in the pound; the pauper is luxuriously provided for in hundreds
of ways lest he should starve, feel the cold of winter or suffer
any other form of discomfort; he need only do a few days’ work
to receive a living wage for months (called “ the dole *’); the sick
and wounded are treated with care and skill never before ex-
perienced in the history of the world and restored to their families
to procreate children, perhaps with a predisposition to the disease
of their father. Melancholiacs are cared for in asylums, restored
to health and sent forth to the world to beget more melancholiacs,
instead of being allowed to terminate their disease in Nature’s
way, Suicide; or, regarding the matter from another point of view,
they are sent back to their families with the result that the
unfortunate influence of their psychotic peculiarities upon their
own children is resumed and maintained so as to make their
progeny psychotic.
The pith of the whole matter is this: that among savage
' peoples the interests of the individual are subordinated to those
of the race and natural selection is at work; while among civilized
nations the interests of the race are subordinated to those of the
individual, natural selection is allowed full play, and the result
is the survival of the unfitiest. This is the true cause of the
increase of insanity, if we are to attach importance to the
doctrine that mental disease, or the psychopathic tendency, is
inherited.
But there is an alternative explanation of the fact that insanity
is essentially a disease of civilization. The most important
characteristic of civilized communities is repression of all thought
respecting the animal instincts, which exist in every member of
the human species, however much he may refuse to admit the
fact. Now repressed thoughts, aspirations and tendencies are
liable to escape the repression in disguised, symbolic or symptom-
atic form under certain conditions, and one of these conditions
is some abnormal psychical relationship to one or other parent,
surrogate of the parent, or sometimes grandparent or other
relative intimately associated with the subject during infantile
life. Such abnormal psychical relationships are brought about
by mental peculiarities of the father or mother or the surrogate
of one of them, at any rate in the child’s mind. In this way
neurosis or psychosis may be induced, not by hereditary in-
208 MIND AND ITS DISORDERS
fluence, but by the child’s personal! experience of its progenitors
or their representatives in his mind.
War with its attendant stresses and privations has hitherto
been regarded as a potent cause of insanity; but our late ex-
perience of the most terrible war in history is that psychosis
is not abnormally frequent under war conditions. It is only
too true that psycho-neurotic, especially hysterical, states such
as the so-called shell-shock, which is no new disease as some
would have us believe, were extraordinarily common as a result
of the War; but they were rarely sufficiently pronounced to
constitute insanity. Later we will refer to some other neurotic
conditions apparently induced by the war.
There is a popular idea that association with the imsane is
liable to produce mental disorder, and the relatives of an insane
patient often bring this forward as an argument against asylum
treatment. This notion is not supported by facts; for about
40 per cent. of asylum patients are discharged recovered and
the incidence of insanity among attendants on the insane is
small. It occasionally happens, however, that two maiden
ladies, who have lived together and had little communication
with the outside world for many years, both develop a form of
paranoia in which they have the same delusions. This condi-
tion has been called folie a deux, or communicated insanity.
Superficial considerations would appear to suggest that alcohol
is a frequent and potent cause of insanity, but it is difficult to
obtain statistics on the matter because alcoholism is too fre-
quently regarded as the cause of an attack when in reality it has
only appeared as the first symptom. Some years ago, alcohol
was one of the attributed factors of insanity in 4 to 5 per cent.
of the Bethlem cases, but true alcoholic insanity formed only
2 per cent. of the cases. It is much less than that now. We
must, however, recognize that alcoholism is itself a mental dis-
order, usually traceable to repressed homosexuality, and there
are further causes behind this. Moreover, the more we investi-
gate alcoholic psychoses, the more we are led to the conclusion
that they are ordinary biogenetic psychoses in which alcoholism
is a Superadded factor.
The same remarks apply to drug habits and the insanities
occurring in some cases, apparently as a direct effect of the drug.
Sexual excess is rarely a cause of insanity, although it is fre-
quently described as such. A sexual outburst is liable to occur
in the earlier stages of many insanities in which the patient loses
PHYSICAL CAUSES 209
cases sexual excess is a symptom, not a cause. The question
is often asked: ‘‘ What is sexual excess ?’” No numerical defini-
tion can be given; sexual excess is indulgence in the sexual act
- with such frequency as to be deleterious to health. When
the result is disorder of the nervous system the most common
form of disease is, in the author’s experience, a mild form of
chronic nervous exhaustion, somewhat resembling neurasthenia,
but it is not common.
Masturbation stands in much the same position. Rarely a
cause of insanity, it is rather to be regarded as a symptom.
Neuropathic individuals are frequently addicted to the vice
because they are often emotionally fixated in the infantile auto-
erotic phase of development. It is said to be common among
some geniuses. Voltaire in his later years confessed to having
masturbated all his life. Masturbation is liable to occur in the
earlier stages of many forms of insanity for the same reason as
other sexual outbursts. In some cases of stupor associated with
peripheral analgesia characteristic of mental disorder, masturba-
tion arises as the direct result of the anesthesia. Consciousness
being dependent upon sensation, in states of peripheral anes-
thesia it is dependent upon sensations arising in the sensitive
remainder; the patient’s attention is thus directed to the genital
region and he acquires the habit of masturbation. In some
persons persistent masturbation induces a state of chronic
nervous exhaustion closely resembling neurasthenia. True
neurasthenia, on the other hand, is caused by the conflict between
the unconscious urge to masturbate and the conscious desire to
refrain from the act, the result being a more or less successful
repression of masturbation.
Functional disturbances of the brain may result from disease
of other organs. Dr. Head has shown that the pain of visceral
diseases occasionally gives rise to hallucinations of vision,
hearing or smell, or to states of depression or exaltation; the
psychical mechanism of this will be explained later. Pain in
the epigastrium, often due to indigestion, is especially liable to
cause depression, quite independently of the possible absorption
of noxious products of disordered digestion: a blister applied to
the epigastrium will sometimes cause depression of this nature.
Possibly the depression associated with constipation can some-
times be explained in this way.
Mickle studied the mental symptoms associated with the
various forms of cardiac and arterial disease. In the earlier
stages of aortic regurgitation depression is the rule; but in the
14
210 MIND AND ITS DISORDERS
later stages when the heart is failing the patient is usually excit-
able and exalted. Aortic stenosis is said to be associated with
impulsiveness, violence and delusions of persecution. It is more
frequent in general paralysis than in any other forms of insanity,
syphilis being the most important cause of both general paralysis
and endarteritis. Mickle stated further that mitral regurgita-
tion tends to depression, and degeneration of the cardiac muscle
to motor restlessness. These observations are in accord with
those of Craig, who found that states of depression are associated
with high blood-pressure and states of motor restlessness with
low blood-pressure. Motor restlessness frequently appears in the
later stages of wasting diseases when the blood-pressure is low.
Similarly depression is the rule in cases of Bright’s disease,
the blood-pressure being high; but in the last stages of that
disease, when the blood-pressure falls, the patient is liable to
become restless and excited. Uremic states in which the nervous
system is subjected also to toxic influences are characterized
by hallucinations, especially of vision, accompanied by agita-
tion gradually changing to stupor which deepens to coma in the
terminal stage.
Diseases of the thyroid may lead to various forms of insanity
which will subsequently be considered in detail. Pituitary
defect may also be accompanied by mental symptoms.
Infectious disease and other exhausting conditions charac-
teristically give rise to acute confusional insanity.
Insanity is closely allied to other functional nervous diseases};
it is sometimes ushered in by an attack of apparent neurasthenia,
chorea or hysteria in some form, while one-sixteenth of the
asylum population of this country suffers from epilepsy.
Inasmuch as the cerebral cortex is recognized to be the physical
basis of mind, it might naturally be supposed that mental
disorder would be a common, if not the usual, result of gross
organic lesions of the cortex; but, as a matter of fact, organic
insanity is by no means common. When a person becomes
hemiplegic as a result of thrombosis of the middle cerebral artery,
the mental disorder which results is loss of voluntary action and
perhaps excess of emotional reaction on one side of his body;
but such mental disorder cannot be characterized as insanity.
Incidentally a few of these patients become certifiably insane
and then their insanity is frequently accompanied by symptoms
which have been regarded as characteristic of organic disease.
The various types of organic insanity will, however, receive
consideration in due course,
CHAPTER IT.
THE PHYSICAL STIGMATA OF DEGENERATION.
WE have seen that many cases of mental disease are induced by
stresses acting upon an unstable nervous system, such stresses
as have little or no deleterious influence upon the mentation of
a normal individual; and the question arises whether there is
any way of recognizing that a given individual runs unusual
risk of mental disease from exposure to the ordinary stresses
of life. A medical man may, for instance, be consulted as to
the possibility of this or that occupation being too strenuous for
a certain member of a family when another member is afflicted
with mental disease, the person in question never having shown
signs of nervous debility.
Under such circumstances the physician may have to rely
_ upon the general configuration of the individual and to determine
whether his limbs and other parts of his body are well shapen
and proportionate to one another. In other words, he looks
for the physical stigmata of degeneration. These are of three
classes:
1. Anomalies in the shape of the skull, these being dependent
upon anomalies in the shape of the brain.
2. Anomalies which show a tendency on the part of the in-
dividual to revert to an ancestral type (atavism).
3. Deformities which show evidence of incomplete develop-
ment.
Cranial Anomalies.—Marked asymmetry of the skull is to be
regarded as a stigma of degeneration. Slight asymmetry is
unimportant, since it frequently occurs in normal individuals,
especially in the frontal region.
The normal circumference of the skull is 224 inches for a
person of average size. A deviation of more than 24 inches from
this standard in either direction is to be regarded as abnormal,
although exceptional individuals have been known whose cranial
circumference measured only 18 inches on the one hand and
37 inches (hydrocephalus) on the other, whose intellectual
functions were but slightly, if at all, deficient.
2I1
212 MIND AND ITS DISORDERS
The antero-posterior diameter is normally about 7? inches,
the greatest transverse diameter being 6¢ inches.
The binauricular diameter (calliper measurement from one.
auditory meatus to the other) and the length of the face from
the root of the nose to the lowest part of the chin should each
be about 54 inches; and the binauricular arc and naso-occipital
arc (root of nose to occipital protuberance measured over the
highest point of the skull) should each be about 14 inches.
Broadly speaking, an individual is to be regarded as abnormal
if his measurements differ more than 15 per cent. from the above,
and as a degenerate if the measurements are more sie. I5 per
cent. below the normal.
The cephalic index or index of breadth is found by multiplying
the breadth by 100 and dividing by the length:
breadth x 100
length
From the hats stocked by hatters we may infer that the usual
cephalic index in this country is 79. Indices below 77 are said
to be dolichocephalic; 77 to 81, mesocephalic; and above 81
brachycephalic. Peterson of New York regards all indices
between 70 and go as falling within normal limits, but such a
view is probably too liberal.
Platycephalus is a condition in which the top of the head is
abnormally flat.
Acrocephaly is the dome-shaped skull. It is commonly asso-
ciated with dolichocephaly and, according to some authorities,
with genius.
Atavistic Anomalies.— Man as compared with the lower
animals is characterized by great development of the cranium
and small development of the jaws, so that his face is vertical,
whereas the face of the animal is rather horizontal. Accordingly
prominence of the jaws with recession of the forehead (prog-
nathism) is an atavism in man, and therefore a stigma of de-
generation. The facial angle is the angle, seen in profile, formed
by a line drawn from the middle of the supra-orbital line to
the margin of the alveolus between the central incisor teeth of
the upper jaw, and a line from the latter point to the centre of
the auditory meatus. This angle is normally about 78 degrees
in the macerated skull. When the angle is more acute than
75 degrees, the skull is prognathous. It is not very difficult to
estimate this angle in the living subject. In any marked case
h
OQ
Fic. 26.—DEFORMITIES OF THE PINNA.
To face p. 213
DEFORMITIES OF THE PINNA 215
the facial aspect is sufficiently striking for prognathism to be
recognized by the unaided eye.
Similarly the lower animals, the proboscis monkey excepted,
have a broad flat nose as compared with man; and a broad flat
nose in man (except in the black races) is an atavistic stigma of
degeneration. ;
Other recognized facial stigmata are great prominence of the
malar bones and marked asymmetry of the face.
Deformities of the Pinna.—These are of frequent occurrence
and, if well marked, of considerable importance. Peterson dis-
tinguishes twenty-two varieties, as follows:
1. Abnormal implantation: the ears project too far (Fig. 26, a)
or are placed too high, too low or too far back on the head.
2. Excessively large ears.
3. Excessively small ears.
4. Too markedly conchoidal shape, the antitragus, antihelix,
and crura furcata being insufficiently developed; while the helix
outlines the ear “like the rim of a funnel”.
5. Excessive or deficient length, excessive breadth of the upper
part or absence of the lobule.
6. A long ear with constrictions in its breadth (Fig. 26, 0).
7. The Blainville ear: asymmetry, usually due to anomaly of
the left ear.
8. Absence of the lobule, commonly associated with other
deformities. }
g. Adherent lobule inclining downward toward the cheek
(Fig. 26, c and a).
10. Stahl ear No. 1. The helix is too broad and coalesces
anteriorly with the inferior crus.
11. The Darwin ear, which is characterized by a prominent
point of cartilage at the upper and posterior part of the rim—
the point of the ear in lower animals (Fig. 26, /).
1z. The Wildermuth ear, in which the antihelix is more promi-
nent than the helix. This is very common (Fig. 26, d).
13. Absence of the antihelix and crura furcata (Fig. 26, a).
14. Stahl ear No. 2, in which there are three crura instead
of two.
15. Wildermuth’s Aztec ear, in which the crus superius of the
antihelix is continuous with the helix anteriorly, and there is no
lobule.
16. Stahl ear No. 3. The antihelix and antitragus are joined
together by a ridze and the superior crus is wanting (Fig. 26, 7,
approaches to this condition).
214 MIND AND ITS DISORDERS
17. Reduplication of the helix; overfolding of the helix
(Fig. 26, g and /; a pin is held in position by the overfolded
helix in g).
18. Too large or too small a concha.
19. The scaphoid fossa is continued into the lobule (Fig. 26, e).
20. The Morel ear, in which there is defective formation of
the helix, antihelix, scaphoid fossa and crura furcata. It is
unfolded, flat and thin at the edges, like a plate, and generally
larger than normal (Fig. 26, /).
21. Irregular thickenings of the cartilage.
22. Various anomalies such as clefts, accessory auricles, and
abnormal hairiness of different parts of the pinna.
Of ‘all these anomalies, probably the least important is the
MonTHS LATER.
adherent lobule. This occurs in 20 to 30 per cent. of normal
people, but it is twice as common among degenerates.
This is a convenient place to mention the so-called “ insane
ear ’’ which presents a shrivelled appearance as the result of a
previous “‘ hematoma auris’’, otherwise called “‘ otheematoma ”’.
Although this occurs among perfectly normal people as the
result of severe injury to the pinna, especially from blows received
in the football field, it occurs with abnormal frequency among
the insane. It is mostly seen in cases of general paralysis,
epilepsy and katatonia. There is usually, but not always, a
history of some slight injury to account for the condition, such
as holding the patient’s head firmly between the hands during
the process of artificial feeding.
Siz *f a2v/ OF
‘YAMO'T AHL NI
SHAILISOJ ‘MOW UAddQ AHL NISHAILVOAN ‘“SALWIVG GAWNOAAC AO SLSV)— '6z ‘DVT
‘DEFORMITIES OF THE PALATE 215
Hematoma auris makes its appearance as a thickening or
swelling in the neighbourhood of the antihelix. This swelling
gradually increases in size and may spread over the whole surface
of the pinna until, after a few days, it looks like a dusky bluish
egg on the side of the head. In the course of some months the
swelling subsides, leaving the ear deformed and shrivelled.
The recognized treatment of the condition is to blister the skin
over the tumour with liquor epispasticus.
If the tumour is incised, it is found to contain normal blood,
separating the perichondrium from the cartilage; but this should
not be done lest it lead to suppuration.
Ford Robertson has shown that hematoma auris is the result
of degeneration of the ear cartilage, affecting at first the cartilage
cells and then the elastic fibres, which become fluid. In this
way small cysts are formed near the surface of the ear cartilage;
the walls of these then become vascularized. The new vessels in
turn degenerate, rupture and distend the cysts with blood. The
hemorrhage increasing gradually strips the perichondrium from
the cartilage and ruptures pre-existing vessels during the process,
which continues until the pressure becomes sufficient to arrest
further hemorrhage. The blood then clots and the serum
expressed from the clot becomes absorbed in the course of a few
months, during which process the ear shrivels.
Deformities of the Palate.—In a normal person the arch of the
hard palate is large and wide with a moderately high vault.
Generally speaking, the degenerate palate is too high and narrow.
Peterson classifies degenerate palates as follows:
I. Palate with Gothic arch. The centre of the cast of the
palate is somewhat pointed. The arch may have either a high
or low pitch and it may be short or long.
2. Palate with horseshoe arch, comparable to the arch of
Moorish architecture. The alveolus projects into the cavity of
the mouth, so that a cast is either impossible or has to be taken
in several sections.
3. The dome-shaped palate.
4. The flat-roofed palate.
5. The hip-roofed palate, in which the antero-posterior arch
is too pronounced. Artificial feeding may be extremely difficult
in the case of a resistive patient with this form of palate.
6. The asymmetrical palate.
7. The torus palatinus, a bony thickening of variable shape
in the neighbourhood of the intermaxillary suture. Peterson
regards this anomaly as the least important of these deformities.
216 MIND AND ITS DISORDERS
From a study of the palates of fifty-six patients at Claybury
Asylum, Dr. E. H. Harrison came to the conclusion that the
palate indicative of “insane heredity ”’ is a low, broad palate,
which is shallow or of average depth (114 millimetres) opposite
the first bicuspids; while the palate indicative of “ general
degeneracy ’’ (from rickets, congenital syphilis etc.) is charac-
terized by an increased depth opposite the first bicuspids.
Other anomalies of the mouth, which are recognized as stig-
mata of degeneracy, are too much corrugation of the palate
behind the incisor teeth, malpositions and irregularities of the
teeth and delayed dentition. An abnormally long tongue is also
one of the stigmata; the tongue is nearly always too long and too
wide in cases of Mongolian idiocy.
The lower jaw may be abnormally developed and in some
idiots has a bony prominence in the middle of the lower border,
the “‘lemurian apophysis ’’ of Albrecht.
The most important congenital anomalies of the eyes in this
connection are epicanthus (a fold of skin overlapping the internal
canthus, usually symmetrical), irregular or unequal colouring
of the irides, coloboma iridis, persistent pupillary membrane,
retinitis pigmentosa, and high degrees of myopia and hyper-
metropia sufficient to cause spasmodic strabismus.
Degenerative Stigmata in the Limbs.—These are asymmetry,
fusion of fingers or toes, supernumerary fingers and toes, small
Fic. 30.—SIMIAN THUMB OF A PATIENT SUFFERING FROM
DEMENTIA PRACOX.
Diminished internal rotation during flexion of the terminal phalanx.
thumbs, an unusually large number of fine lines in the palm of the
hand, and laxity of the ligaments so that the fingers can be
easily bent back to a right angle; an adult Mongol idiot can
put his toe into his mouth. I have also observed in cases of
idiocy and dementia preecox that the thumb tends to face forward
OTHER DEFORMITIES 217
Fic. 31.—NoORMAL THUMBS, FLEXED TO SHOW THE INTERNAL
ROTATION OF THE TERMINAL PHALANGES.
Fic. 32.—-SIMIAN HAND OF A PATIENT SUFFERING FROM
DEMENTIA PR2ECOX.
The thumb faces forward like the fingers. Note also the shortness of
the little finger and the flatness of the thenar and hypothenar eminences.
218 MIND AND ITS DISORDERS
like the fingers, instead of looking across the palm, and that the
terminal joint of the thumb does not undergo the normal amount
of internal rotation when it is flexed. These features may also
be observed in the thumb of the chimpanzee.
Cutaneous Stigmata.—These are mostly anomalies in the growth
of hair, such as glabrous chin in men, abnormal growth of hair
on the face and breasts of women and along the spinal column
in either sex, and a double or eccentric whorl at the vertex of
the scalp. Irregular pigmentation of the skin, as in vitiligo, and
nevi, are also regarded by some as stigmata of degeneracy.
Adenoma sebaceum is a disease found only in a certain form of
idiocy. Longitudinal ridging of the nails is said to be indicative
of a tendency to neuropathy.
Many regard as stigmata all anomalies showing evidence of
incomplete development. These include hare-lip and cleft palate,
meningocele and spina bifida, stunted limbs, congenital disloca-
tion of the hip, congenital heart disease, hernize, hypospadias,
epispadias and ectopia vesice, imperforate anus, imperforate
vagina, uterus bicornis, undescended testicle, and hermaphrodi-
tism. An unnaturally youthful face surmounting an adult body
is a Stigma familiar to all.
General Abnormalities.—Giants, dwarfs and persons in whom
the relative proportions of the various parts of the body to one
another are abnormal, are generally to be looked upon as de-
generates.
Conclusion.—In view of the existing tendency to ascribe
mental disease to the circumstances of the patient rather than
to prenatal influences, the question arising out of this chapter
is:—‘‘ To what extent are the physical stigmata of degeneration
due to the environment of the individual and how many of
them are of congenital origin ?’’ Up to the present time the
question remains unanswered.
NEUROSIS.
THE functional mental disorders are classified as neurosis, psycho-
neurosis and psychosis according to the age at which the patient’s
libido has become fixated. In neurosis the etiological factors
belong to the present or comparatively recent life of the patient
and not to childhood, as in psychoneurosis, or to babyhood as
in the psychosis.
Freud has further pointed out that the fundamental difference
between a psychoneurosis and a psychosis is that the former is
the result of a conflict between the ego and its 7d (corresponding
unconscious) and the latter is the analogous outcome of a similar
disturbance in the relation between the ego and the outer world
(reality). There is only one true neurosis, viz., the anxiety
neurosis.
Freud classifies neurasthenia as a neurosis, and ascribes it to
excessive masturbation or pollutions, but he means something
different from the neurasthenia hereinafter described as a psycho-
neurosis. Freud’s “‘neurasthenia’’ is more like Kraepelin’s
“chronic nervous exhaustion ', which resembles true neuras-
thenia so closely that some writers have called it ‘“‘ acquired
neurasthenia’’. The causes of this disease are those of acute
confusional insanity (Chapter XIV.), and masturbation is cer-
tainly not the only etiological factor.
CHAPTER TIT:
THE ANXIETY NEUROSIS.
ALTHOUGH the causation of this neurosis is of a psychical nature,
its symptoms are mainly physical, so much so that it is unusual
for a patient suffering from this disorder to consult a mental
specialist in the first instance. It receives its name from the fact
that the symptoms represent the physical accompaniments of
anxiety or fear.
Etiology.—It has long been recognized that morbid anxiety is
a hyper-excitation process, but it remained for Freud to discover
its source. He made the discovery that the anxiety neurosis is
begotten of sexual excitations which are unable or not allowed
219g
220 MIND AND ITS DISORDERS
to follow their natural course of leading to either physical grati-
fication or even conscious desire for this. Now when desire of
any kind is repressed into the unconscious, it becomes replaced
in consciousness by its opposite—viz., fear; but not necessarily
fear of the particular object which is unconsciously desired, but
an ill-defined apprehension which causes the subject to fix his
dread upon other objects, especially those which tend to remind
him of the original object of desire. The reason why the re-
pression of sexual desire is especially potent is merely that sexual
desire is infinitely more liable to be repressed than any other.
The condition which is responsible for the anxiety neurosis
is, then, sexual stimulation without gratification. This state of
affairs is most frequently brought about by coitus interruptus
commonly practised by married couples who do not wish for a
child; but also by pernicious devices for the prevention of con-
ception. Intentional abstention, prolonged engagements, early
widowhood, and enforced separation of husband and wife as,
for example, during the recent war, are all responsible for a
number of cases. A disproportion between desire and potency,
after the age of fifty, for example, is sometimes an etiological
factor, and a few cases occur as a result of the renunciation of
masturbation. The above observations are obtained from direct
clinical investigation, not by psycho-analysis.
Mental Symptoms.—The patients are usually hypersensitive,
especially to noise and bright light, sudden accesses of which
cause them to start. There is little or no disorder of the percep-
tive faculty, but some authors mention hallucinations as an
occasional symptom. Volition and attention are only disturbed
in association with some emotional outburst.
The chief mental symptom is a general emotional tone of
anxiety or apprehension. The patients are afraid to open detters
lest the contents convey bad news; for the same reason, they are
in terror of telegrams. Any slight passing indisposition, either
of themselves or of their loved ones, induces alarm that it may
be symptomatic of some deep-lying fatal disease. All fleeting
incidents are likewise apt to be misinterpreted. The patients
exhibit abnormal terror in the presence of any real danger, such
as an air-raid, which often caused them to fall into a state of
collapse. The reason for this will be obvious to every psycho-
logist who has made a study of the unconscious, and the most
superficial analysis of such patients reveals the phallic signifi-
cance or symbolism (in their minds) of Zeppelins, aeroplanes
and bombs.
ANXIETY NEUROSIS 221
Apart from this persistent apprehensiveness, the patients are
subject to attacks of anxiety without any apparent cause. With
such attacks are frequently associated a sense of impending
death or any of the circulatory, respiratory, digestive and other
disturbances below specified. Insomnia is common and is
sometimes induced by night terrors. Some patients complain
of vertigo or various pareesthesie.
Physical Signs.—Although the above-mentioned attacks of
anxiety are frequently accompanied by the following physical
signs, they may and usually do occur quite independently of
conscious anxiety; they must therefore be regarded as rudi-
mentary symbols or equivalents of anxiety. They are—
(a) Palpitation, tachycardia, pseudo-angina and cardiac irregu-
larity.
(5) Vasomotor constriction, with coldness or blueness of the
extremities.
(c) Respiratory oppression, air hunger and attacks of asthma.
(d@) Dryness of the mouth, nausea and even actual vomiting,
diarrhoea, bulimia and other digestive disturbances, which in time
may lead to a certain amount of gastric dilatation, consequent
' organic dyspepsia and even enteroptosis.
(e) Perspiration, often nocturnal, and especially of the palms
of the hands in the daytime.
(f) Polyuria and frequency of micturition.
(g) Tremor, fits—apparently of an epileptic nature—and even,
it is said, loss of consciousness without convulsion.
Pathology. — The reader will have noticed that all these
phenomena are the usually recognized physiological accompani-
ments of anxiety, dread or terror; although fits and loss of con-
sciousness are extremely rare, as indeed they are in the anxiety
neurosis.
The bodily changes above mentioned constitute the whole
morbid anatomy of the condition, for there is none other. When
anxiety is repressed from the conscious into the unconscious (as
well as the desire above mentioned), it tends to find expression
in symbolic form as one or more of the physical manifestations
of fear. In accordance with our theory of the emotions, such
manifestations cannot occur without inducing conscious anxiety.
This may be repressed in turn and so a vicious circle be set up.
Now the original view with regard to the pathology of the
anxiety neurosis was that its foundation is of a physical nature,
being caused by defect of physical gratification—in other words,
it is due to a retention of products which should have been
222 MIND AND ITS DISORDERS
excreted. Experience teaches us, however, that an adjustment
of the etiological conditions does not always cure the disease.
Why ? Because the psychical vicious circle is still active in the
anxiety neurosis and is obliged to find expression in symptomatic
guise. It is now, therefore, considered that the foundations of —
this neurosis are psychical, as well as physical.
Prognosis.—As long as the two causal factors, sexual stimula-
tion and lack of sexual gratification, remain operative, the anxiety
neurosis tends to get worse; but, as a rule, it gradually improves
and disappears after either of these factors has been removed.
The anxiety of widowhood, for example, passes away in due
course. Other cases recover by voluntary compliance with the
requirements of Nature; but not all, for it is often found that , after
the specific etiological factors have been adjusted a certain amount
of anxiety hysteria remains which requires some psycho-analytical
investigation to complete the cure. For this reason it is not a
bad diagnostic error to call a case of the anxiety neurosis anxiety
hysteria; but the converse—so common among neurologists—is
a bad mistake. For example, these would diagnose anxiety
neurosis in “shell-shocked ”’ soldiers from the front during the
War and then utilize their erroneous diagnosis to argue against
the sexual causation of this disease. But this is a digression.
So far as I am aware, a fatal issue is unknown; but the possibility
of suicide should be borne in mind.
Treatment.—Whenever it is possible for the patient to re-
adjust his or her abnormal sexual life, this should be done. The
practice of coitus interruptus must be substituted by a state
of affairs in which the patient obtains normal gratification,
and prolonged engagements should be terminated, preferably by
matriage.
It occasionally happens, however, that circumstances will not
allow of this readjustment; for example, the enforced separation
of young husbands and wives during the War. Under such
conditions the patients should be treated with anaphrodisiac
medicines, of which the bromides are the most satisfactory.
Monobromate of camphor is probably the best, but sodium
bromide in 10-grain doses three times a day is quite a useful
drug for such patients. On the other hand, when the patient is
able and willing to comply with the doctor’s advice, but finds—
as frequently happens—that the neurosis has rendered him
sexually anesthetic, tonic aphrodisiacs should be given, of which
strychnine in some form or other is the best.
After coitus the blood of the female gives a prostatic Abder-
ANXIETY NEUROSIS 223
halden reaction, but only if semen has been in actual contact
with the mucous membrane of the vagina. I have therefore
treated a few cases of the anxiety neurosis recently in women
by the administration of prostatic extract. The results have
been sufficiently gratifying to induce me to adopt this line of
treatment in many Cases.
Lastly, it is sometimes found that the renunciation of an
abnormal sexual life, even when aided by judicious medicinal
treatment, is not of itself sufficient to alleviate the disorder.
It then becomes necessary to resort to psycho-analysis in order
to reveal those complexes responsible -for the failure, and thus
to complete the cure.
THE PSYCHONEUROSES.
THESE (neurasthenta, hysteria and the compulsion neurosis) differ
from the neuroses in that they owe their origin, not to existing
conditions, but to partially or completely forgotten situations,
incidents or phantasies of childhood, whose persistence in sym-
bolic form into adult life, or the reactions against them, or
a compromise between the phantasies and the reactions or
their symbols, appears in symptomatic form, which may even
itself be symbolized.
It need hardly be said that the unravelling of such a com-
plicated tangle is the most difficult task which can present itself
to the medical psychologist. There is certainly no such brain-
wracking work in any other department of medicine or surgery,
or probably in any other profession.
At the inception of a psychoneurosis there is frequently some
exciting determinant which serves as a link with the forgotten
past and is hence commonly but erroneously regarded as the
primary cause of the disorder; attention should not be directed
to this etiological factor so much as to the already existing
mentation of the individual who has been affected by it.
CHARTERS Tye
NEURASTHENIA.
THIS is a disorder which makes its appearance in early adult life
and is chiefly characterized by an increased susceptibility to
fatigue on slight exertion, mental or physical. It appears to
be still necessary to insist that it is a definite disease and not
a “‘ rubbish heap ”’.
Etiology.—The incidence of the malady is much higher in men
than in women and it usually makes its appearance shortly
after the person leaves school—that is to say, during adolescence.
Neurasthenia used to be classed as a neurosis because, being
ascribed to masturbation, its cause was supposed to be more or
less contemporaneous with the disease. In my experience, how-
ever, many neurasthenics (the most severe cases) are incapable
224
NEURASTHENIA 225
of masturbation or, for that matter, of any other variety of
sexual gratification. In fact, masturbation has been more or
less successfully repressed and the disorder is traceable to re-
pressed auto-erotism. Now auto-erotism is an infantile trend,
therefore neurasthenia must be regarded as originating in an
infantile fixation. It must accordingly be classed as a psycho-
neurosis.
It is true that masturbation and sexual excess sometimes
cause a transitory state of nervous exhaustion closely resembling
neurasthenia in some people, but this should not be labelled
neurasthenia’”’, but rather ‘exhaustion neurosis’’. Most
masturbators appear to suffer little or no ill effects from the
practice. On the other hand it must be acknowledged that
neurasthenics are especially hable to a short period of nervous
exhaustion following attempted coitus or, to a smaller degree,
masturbation. Ferenczi has called this condition “ one-day
neurasthenia ’’. In some patients this state of exhaustion does
not occur until the third or fourth day after the sexual act.
Symptoms.—When the patient comes under observation there
is always a history of previous masturbation and of loss of
weight.
There is complaint of general malaise and of never feeling
well. On inquiry after their health, patients commonly reply
that they “‘ don’t feel very grand’’. The complexion is pale
and there is usually a slight chlorosis, the eyelids droop, the
skin is moister than natural and the palms of the hands are
bathed in sweat.
Examination of the chest and abdomen reveals nothing
abnormal except one curious and almost constant feature, a
“ throbbing abdominal aorta’ of which no explanation is forth-
coming. The pulsation of the abdominal aorta is such that it
feels as if the artery were immediately beneath the skin.
On examination of the nervous system there is found to be
no loss of sensation nor is there any general cutaneous hyper-
esthesia. Isolated spots of hyperesthesia may sometimes be
detected. These are commonly situated along the spine and
in the submammary, epigastric and ovarian regions. The testicle
is also tender in some cases while others complain of a pricking
pain in the neighbourhood of the prostate. Not uncommonly
there is hyperesthesia in other sense departments. The patients
cannot tolerate a bright light, and noises which are tolerable
to an ordinary individual irritate them. They are especially
annoyed by crowing cocks and the rumble of traffic. They are
ee
ce
226 MIND AND ITS DISORDERS
particularly sensitive to cold, usually have cold feet and wear
abnormally thick clothing.
The patients complain of all sorts of pains and other sensations
for which no physical basis can be discovered. Specks appear
before the eyes; the head feels numb or empty; there is a sense
of pressure on the vertex or a feeling as if a cap were fitted tightly
over it (symbolically representing psychical repression). In
other cases there is actual aching at the top and back of the
head, but this is unusual. Many patients complain of a
“screwy ’”’ or “‘ crawling ’’ sensation in the neighbourhood of the
occipital protuberance; one patient said that it felt as if a beetle
were lying on its back inside the skull and kicking. Pain at
the back of the neck is a common feature.
Indigestion is a frequent complaint, but investigation asaalie
proves that this is merely epigastric discomfort having no relation
to mealtime, and the appetite is good. Sensations of weight and
of pain sometimes occur in the legs.
There is no disturbance of perception or ideation and hallu-
cinations do not occur, unless the sensations above described
are to be regarded as hallucinations. The memory and judg-
ment are good and the patients have a remarkably clear insight
into their wretched condition.
The emotional tone is usually one of depression, but some
patients become resigned and succeed in maintaining at least
an outward show of cheerfulness. In the depressed cases
emotional reaction is liable to be excessive; tears are frequent
and the patient may even throw himself on his bed and in
anguish bury his face in his hands. In a few of these cases
attempts at suicide are made.
Some of the patients are apt to be moody, irritable, aggressive
and quarrelsome; they are exacting in their demands and take
pleasure in giving trouble to others. Such symptoms are usually
related to constipation and unconscious anal erotism.
Distractibility is a marked feature. By this is meant that,
while voluntary attention is with difficulty maintained, instinc-
tive attention is easily aroused. The result is that the attention
is constantly wandering and the patients are forgetful. The
cause of the difficulty of voluntary attention is that it is accom-
panied by an increased sense of effort and therefore of fatigue.
This brings us to one of the main features of neurasthenia—
viz., defect of volition. The patients are anxious enough to be
busy about their affairs like other people; but all effort, mental
or physical, leads to an intense feeling of fatigue. In many
SYMPTOMS OF NEURASTHENIA 227
cases even the thought of doing anything causes the patient to
tremble and to break into a profuse perspiration (ergophobia).
Hence he lies in bed day after day, week after week and month
after month; but this prolonged’rest does not, at least by itself,
relieve the condition, nor is any benefit obtained by attempting
to fight the disease by working in spite of the fatigue induced.
The beneficial effect of practice in making the subsequent per-
formance of any particular action easier 1s wanting in neuras-
thenia. This symptom is best shown by Weygandt’s method.
The patient is given a sheet of paper with columns of figures to
be added. He starts on the first column and at the end of a
minute writes down his result so far as he has gone. Then he
passes to the next column, adds for one minute and puts down
the result as before, and so on through the whole series. Ina
normal person, at first the effect of practice is noticeable in that
the added portions of the columns get longer and longer until,
fatigue setting in, they begin to grow shorter and shorter. In the
neurasthenic, on the other hand, the added portions shorten
from the very first. Mistakes in the addition also occur earlier
than in a normal individual.
_ Similarly, examination with the ergograph reveals that mus-
cular fatigue sets in early, although the records of the first few
contractions reach an average height. A special exemplification
of this muscular fatigue is the so-called “‘irritable eye’, the
patient complaining that the eyes ache on reading for a short _
time, although no error of refraction is to be found. Examination
with the perimeter soon fatigues the retina, and unless carried
out quickly, the visual field will be found contracted.
Sleep is as a rule fairly good and there is difficulty in waking
in the morning, although insomnia occurs in some cases, especially
during the early hours of the night. Nocturnal emissions are a
frequent complaint and a source of much worry to the patient.
Spermatorrhcea occurs also during the day in some cases. As
already stated, many neurasthenics are impotent or, more fre-
quently, suffer from a severe exacerbation of their symptoms for
some days after attempted coitus. Ejaculatis precox is the rule.
The deep reflexes are usually increased. A peculiar feature
of the knee-jerk, which is excessive, is that its elicitation com-
monly causes the patient “to start’’, and sometimes even
induces a sharp sensation in the back.
The urine is to be regarded as normal, since some doubt
has been cast upon the statements that the quantity of urea is
diminished and that of the uric and phosphoric acids increased.
228 MIND AND ITS DISORDERS
Diagnosis.—There is a great tendency nowadays, even on the
”
part of many experienced physicians, to label as “‘ neurasthenia
all functional nervous disorders which for the moment cannot
be pigeon-holed. Doubtless this is partly due to inaccurate
descriptions of the disease which appear from time to time. .
In one description which I have before me, I note that some
cases are said to drift into melancholia, others are patients with
obsessional insanity suffering from morbid fears such as claustro-
phobia and agoraphobia. I have even seen it stated that
general paralysis may begin as neurasthenia; this is using the
term as a Cloak for erroneous diagnosis. I need hardly say that
these are not cases of the neurasthenia here described. Under
these circumstances it behoves us to be very careful in the
diagnosis of neurasthenia to exclude all those forms of disease
which are liable to be mistaken for it; not that the diagnosis is to
be arrived at merely by a process of exclusion, for neurasthenia
is a definite disease with definite symptoms. If, however, care
be exercised in the diagnosis, it will be found that it is less
common than is usually supposed.
Chronic nervous exhaustion is the disease which most closely
resembles neurasthenia, so closely indeed that it has received
the name of ‘acquired neurasthenia’’. Chronic nervous
exhaustion differs in being a disease of middle life, usually
traceable to some exhausting influence on the nervous system.
The War was responsible for many cases of this type which were
erroneously labelled “‘neurasthenia’’ for political reasons.
The other essential difference is that peripheral analgesia is
present in chronic nervous exhaustion, at least in the earlier
stages.
Hysteria is often mistaken for neurasthenia, so much so that
hysteria due to traumatism is often called “‘ traumatic neuras-
thenia’’. Localized anesthesia and paralysis do not occur in
uncomplicated neurasthenia. I hope that the chapter on
hysteria will convince the reader that there is not the least
resemblance between the two diseases.
Melancholia, especially the hypochondriacal form, is sometimes
mistaken for neurasthenia. Such an error is avoided by atten-
tion to detail. Melancholia begins more acutely, and usually
at a later period of life than neurasthenia. The neurasthenic
does not present the characteristic attitude of the ede cholidtl
there is no rigidity, and the small brisk knee-jerks of melancholia
contrast strikingly with the extensive knee-jerk of neurasthenia.
Lastly, the hypochondriacal melancholiac suffers from delusions
DIAGNOSIS OF NEURASTHENIA 229
about his health and has no clear insight into the nature of his
malady like the neurasthenic.
Hypochondnacal paranoia begins much later in life than
neurasthenia, and the patients, like the melancholiacs, suffer
from delusions and have no clear insight; nor have they the
fatigue symptoms of the neurasthenic.
In any case of persistent headache the physician should always
be careful to exclude the existence of organic intracranial disease
before diagnosing neurasthenia. The optic discs should always
be examined for neuritis. Differences between the reflexes of
the two sides should put the medical man on his guard.
The early stages of general paralysis and tabes dorsalis some-
times exhibit a superficial resemblance to neurasthenia. Careful
examination of the light reflex and due consideration of the age
of the patient are the most important points in the diagnosis.
Osler stated that exophthalmic goitre may in its early stages
resemble neurasthenia. We ought therefore to examine all
suspected cases of neurasthenia for tremor, tachycardia and
enlargement of the thyroid body.
Lastly, it must be insisted that a careful systematic examina-
‘tion of all the organs of the body should be made, so as to be sure
that the nervous disorder is not secondary to such conditions as
gastric catarrh, phthisis, anemia or any other such organic disease.
Prognosis.—This is entirely governed by the treatment, with-
out which a neurasthenic cannot recover. He may have his
good days as well as his bad, but any attempt to do a day’s work
is sure to be followed by a relapse. Some of these patients
develop paranoia in after years. Indeed paranoid symptoms
frequently manifest themselves during the psycho-analytic treat-
ment of even early cases.
Treatment.—There is only one certain cure for neurasthenia—
viz., psycho-analysis; but, inasmuch as most neurasthenics
cannot afford this mode of treatment, can anything else be done
to ameliorate their condition ? The answer is definitely “‘ No !”’
In spite of the multiplicity of wonderful formule recommended
by manufacturing chemists for neurasthenia, not one of them is
of the slightest use; and if some day some mitigating drug should
be discovered, it should not be prescribed because these patients
would soon become slaves to it.
Neurasthenics should be advised to avoid becoming vale-
tudinarians, npt to give way to their symptoms, but to continue
work (or play) in spite of its fatiguing effect. Otherwise, the
malady is sure to go from bad to worse.
CHA PRE heave
HYSTERIA,
IN a previous edition of this work the hypothesis of Babinski
was adopted—that hysteria is a disorder which arises as the
result of suggestion, but further psychological investigation has
shown this view to be at least incomplete; it will therefore not
be mentioned further in this edition, despite the acknowledged
fact that an hysterical symptom can frequently be both pro-
duced and cured by suggestion or persuasion with or without
hypnosis.
Janet’s conception is that hysteria is ““a form of mental
depression characterized by restriction of the field of personal
consciousness, and a tendency to dissociation and emancipation
of the systems of ideas and functions that constitute personality.
Hence there is a tendency to complete division of the personality,
and subconscious mental conditions grow and form a kind of
, second personality ’’. This view is that the patient is in a state
of absentmindedness, a sort of amnesia.
Since Janet enunciated this hypothesis, psycho-analytic in-
vestigation of hysterical patients has shown it to be correct;
but it has carried us a step further than Janet. We have seen
that a division of the personality exists in everybody, and Freud
has shown that the hysterical symptom represents in symbolic
form a compromise between an unconscious wish and its con-
scious inhibition or repression. For example, an Englishwoman
married to a German, who had been interned, was told by him
that, after the War, she would have to go with him to Germany
and to live there with him. Asa result she developed hysterical
paraplegia, symbolizing that she could not “go’’. The para-
plegia was a compromise which satisfied both conditions; her
unconscious desire to “‘ go with’’ her husband was inhibited by
her conscious desire to remain in England, but her paraplegia
satisfied both conditions, for it excused her from “ going with ”’
her husband and also from going away from her native country.
Etiology.—It sometimes happens that hysteria occurs in
epidemic form. The “‘ dancing mania’’ of the Middle Ages,
230
ETIOLOGY OF HYSTERIA ZL
which sometimes spread through enormous tracts of European
territory, is probably the best example of this; but it is also
occasionally seen to-day in divers forms in schools, nunneries and ~
remote villages. Such cases bring home to us the fact that there
is but little difference between the unconscious desires of every
one of us, and that we all have the same desire to repress them.
When any individual of a community exhibits symptoms which
would effect a compromise between his two personalities, what
is more natural than that other members of that community,
whose conditions are precisely the same, should develop the
same symptoms? It must be admitted that there is an element
of suggestion in these epidemics, but it plays a minor rdéle.
Apart from epidemic influence, superstition and religious
excitement must be regarded as etiological factors. Practical
experience teaches that those who dabble with spiritualism,
theosophy and allied subjects are especially liable to hysterical
manifestations. Moreover, it becomes obvious why they should
do so; for untrained, unscientific conscious attention to the
phenomena of the unconscious tends to bring the conscious and
the unconscious into conflict. Even psycho-analysis is dangerous
' in untrained hands.
The direct exciting cause of an attack of hysteria is usually
some fright, shock or disappointment, not necessarily so severe
that it would make a profound impression on anybody, but of
such a nature that it provokes an abnormal reaction in the
very patient under investigation, because of his special experi-
ences of an earlier date, perhaps of childhood.
Traumatism, especially to the spine, appears to be peculiarly
liable to induce an attack of hysteria and it is particularly potent
when the question of compensation hangs in the balance (under
the Employers’ Liability Act, for example). Indeed recovery
is not to be expected in these cases, even with good treatment,
until the matter of compensation has been definitely settled one
way or the other. This observation has led many to regard
traumatic hysteria (‘‘ traumatic neurasthenia’’ as it used to be
called) as nothing more than malingering. The War has produced
thousands of these cases of traumatic hysteria and helped to
eradicate the notion that the disease is a sham. The converts
do not, however, accept the teaching of those who have made a
special study of the neuroses, but attempt to treat such patients
on the supposition that “ shell-shock”’ (as it has been named)
is a neurosis Closely allied to malingering.
Our soldiers at the front were all exposed to much the same
232 MIND AND ITS DISORDERS
conditions, but only a relatively small number suffered from
traumatic hysteria, a fact which indicates that there is yet another ©
etiological factor in these cases. This is the already existing
mental state of the soldier whose nervous system succumbs to
his war experiences without actual injury. Investigation has
shown that the particular circumstances which determine the
hysterical symptoms usually possess a symbolic value for the
patient owing to pre-existing worries, usually of a domestic
nature and often of remote date, which he has wished and
attempted to put out of his mind, perhaps so successfully that
they have become unconscious.
In all disease there is a certain amount of reciprocity between
the predisposing and exciting causes. So it is with hysteria.
With great predisposition an apparently trifling incident may be
sufficient to bring a train of hysterical symptoms into existence,
and wice versa. Now by far the majority of our soldiers who
suffered from ‘“‘ war shock’”’ were but little predisposed to a
psychoneurosis, but they were exposed to such extraordinarily
trying conditions in the Great War that the influence of the
exciting cause was overwhelming. For this reason it was seldom
necessary to penetrate very deeply into the unconscious minds .-
of these military patients in order to cure them.
It is a remarkable fact that the ancients, in giving a name
to this disease, should have selected one of sexual significance
(Uorépa=the womb). According to their pathology hysteria
was caused by the uterus wandering over the body away from
its proper site, and they used to give valerian to drive it back
again.* Now in the light of psycho-analytic revelations we find
that they were bordering on the truth, and it is easy to see why;
for their primitive mode of thought was more closely allied to
our unconscious than the conscious thinking of modern civilized
people. The hysterical symptom is not due to the presence of
the uterus in the affected part, but it 7s due to a conscious refusal
to give the sexual instinct its proper place, with the result that
some non-sexual part of the body symbolically acquires a sexual
valuation. Symbolically the uterus does leave its normal position
and wander to other parts of the body.
It is still more remarkable that the valerian myth should have
persisted even to the present day; for surely no medical man
in his Holy of holies really believes that he ever cured a true
hysteria with valerian pharmaceutically. We may concede that
* The sexual stimulant effect of valerian upon some of the lower animals
is well known,
CONVERSION HYSTERIA pias!
it has a suggestive value; but this is psychotherapy, not pharma-
cology. Those who still regard hysteria as a variety of malinger-
ing tacitly admit this when they give valerian as a sort of veiled
punishment; but pharmacological rationalization appears to have
gone mad when we read of such drugs as valerianic diethyl-amide
and bornyl-iso-valeryl glycocollate.
Symptoms.—Hysteria may disclose itself in either mental or
physical guise. In the latter case it is known as conversion
hysteria, because the mental compromise is effected through
physical manifestations or symptoms; in mental garb it is called
anxiety hysteria, because the characteristic phenomena are mainly
those of anxiety or fear. There are mixed cases, to be sure,
and those in which one or the other group of symptoms slightly
preponderates; but this is a matter of little practical import
provided that the diagnosis of hysteria is correct for the particular
patient presenting himself for treatment.
The conception of hysteria above adopted precludes us from
accepting as primary symptoms of the malady such phenomena
as hemorrhage, oedema, skin eruptions, muscular wasting, anuria
and fever. These might conceivably occur as secondary symp-
‘toms; for example, hemorrhage frorn the mouth might occur as
the result of some hysterical sucking movement. Or an hysteri-
cal patient might induce some skin eruption for the purpose of
increasing the interest taken in her case; but such an eruption
would be a symptom of malingering rather than of hysteria.*
Conversion Hysteria.
Disorders of Sensation.—Of these perhaps the several varieties
of anesthesia are the commonest. Hysterical hemianzsthesia is
usually complete and extends to the middle line. It generally
affects all the modes of sensation, pain, touch, heat and cold;
but dissociation is not unknown. As a rule, the special senses
of the same side are also involved—viz., hearing, smell, taste and
vision (blindness of one eye, not commonly hemianopia).
It can be demonstrated that the patient really does feel on
the hemianesthetic side in some subconscious fashion by testing
* Since writing the above I have had the opportunity of investigating
psycho-analytically a case of lichen planus, whose etiology is usually—if
not always—psychical. The case proved to be the fulfilment of an un-
conscious wish for self-punishment (masochistic complex) for an unconscious
father fixation (dEdipus complex) plus the fulfilment of a wish for syphilis
(prostitution complex) symbolized by the lichen planus.
Evans and Jelliffe (New York Med. Journ., December 2, 1916) have pub-
lished a case of ‘‘ Psoriasis as an Hysterical Conversion Symbolization.”’
234 MIND AND ITS DISORDERS
him in the following way: Tell him that you are going to touch
him in various parts of the body and that he is to say “ Yes”
when he feels it and ‘‘ No”’ when he does not feel it. In some
cases the patient says ‘“‘ No’’ when touched upon the anesthetic
side, clearly indicating that he does feel (Janet’s sign). Some-
times too he may be awakened from sleep by pricking him on
the anesthetic side. The anesthesia is usually of the left side
(in right-handed patients). This is because the unconscious
confuses “‘ right and left’ with “‘ right and wrong’’. Such loss
of sensation therefore fulfils a desire not to feel or admit some
desire which is “‘ wrong ’’.
More limited areas of anesthesia may occur in the limbs,
their characteristic being that they are ‘“‘segmental’’. The
anesthesia reaches as high as the wrist, elbow or shoulder, or
as high as the ankle, knee or hip on one or both sides. This
anesthesia also affects all the modes of sensation as a rule; but
here again dissociation is not unknown. The limit of the sen-
sation is represented by a line drawn straight round the limb
and there is no shading off: in these particulars, the anesthesia
differs from that which I have described as occurring in states
of exhaustion and in some forms of dementia preecox. “ Stock-
ing ’’ and “ glove’ anesthesia occur similar to that found in some
cases of peripheral neuritis; but there is this difference, that
whereas the limit of the anesthesia in hysterical cases is the
same for all forms of sensation, in peripheral neuritis there is
dissociation at the margin, the loss of sensation for pain, heat
and cold being more extensive than that for touch. Hysterical
anesthesia never follows the distribution of a nerve or nerve-root.
Subjective sensations of hysterical origin also occur, such as
pain in the shoulder (diagnosed as rheumatism, by the way)
symbolizing the burden the patient has to shoulder, stiffness at
the back of the neck symbolizing “ stiffening one’s back”’ in
opposition to difficulties, pruritus ani, pruritus vulve, vaginismus,
dysmenorrhcea and some headaches, all of whose symbolism
becomes clear on analysis.
Blindness of one eye sometimes occurs independently of a
general hemianesthesia, its hysterical nature being demonstrable
by getting the patient to wear prismatic glasses of different
angles in the two eyes, when he sees two objects instead of one.
Hysterical hemianopia also occurs in some rare cases. The
symbolism is obvious; owing to some unpleasant memory the
patient does not wish to see on the hemianopic side. Blindness
of both eyes commonly occurred during the War. Here, again,
HYSTERICAL FITS 235
the symbolism is obvious, for the patient has seen at the front
such horrible sights that he wishes never to see again; and
further psychical mechanisms are easily discovered by analysis.
Various hyperesthetic areas, pains and abnormal sensations
are common in the region of the trunk, usually on the /eft side.
The ovarian and inguinal regions, the lower part of the breast,
the shoulder and the spine, especially over the fifth and twelfth
dorsal vertebre, are the parts most commonly found to be hyper-
esthetic. ‘‘ Hysterical hip’’ and “hysterical shoulder ’’ have a
striking resemblance to organic disease of these joints. Some
patients complain of cardiac pain bearing a superficial resem-
blance to angina. ‘‘ Globus hystericus’’ is a sense of fulness
in the throat accompanied by a feeling of suffocation. Such
symptoms always have a symbolic value. For example, Freud
records a case in which “ globus hystericus’’ symbolized to the
patient “I have to swallow that ’’—“ that’ being an insult by
her husband.
Disorders of Movement.—Of these, hysterical fits are the most
important. The classical description includes two varieties, the
“ hysteroid ’’ and the “‘ hystero-epileptic ’’.
The hysteroid fit may be preceded by an aura of some simple
kind, such as “ globus hystericus ”’ or epigastric sensation, lasting
from a few seconds to a few minutes. The patient then falls
to the ground, but in such a place and manner as to avoid injury
to herself. Rigidity supervenes in which the back is arched so
that the patient rests on her heels and occiput only. The arms
are extended and the fists clenched with the thumbs outside
the fingers or protruding between the index and middle fingers.
This condition lasts from five minutes to an hour or more; the
tongue is not bitten or the urine voided as in epilepsy. The
eyelids are tightly closed and any attempt to open them induces
yet firmer contraction of the orbiculares. This is likely to
mislead the physician into the belief that the patient is malinger-
ing, but such is not the case; the increased contraction is to be
regarded as an unconscious reflex action. If the eyelids can be
separated it will be found that the eyeballs are rolled upward
so that the pupils can only be examined with difficulty. When
this is possible, however, it is found that the reaction to light
is preserved. The conjunctival reflex is also present. The fits
may often be arrested by the application of some strong sensory
stimulus such as the electrical wire-brush, pressure over the
supra-orbital nerves or in the ovarian region. After a fit is
over, the patient on being questioned states that she knows
236 MIND AND ITS DISORDERS
nothing about it; and there is no reason why she should be
disbelieved, for the statements of various patients are in perfect
accord with one another. The fits are sometimes preceded by a
definite epileptic attack; an unobserved attack of minor epilepsy
ushers in a hysteroid fit probably more often than is usually
suspected. This view is supported by the beneficial effect of the
bromides in some of these cases. On the other hand, we meet
with cases in which convulsions occur, exactly like true epileptic
fits in every particular, which are really hysterical. Such cases
may be diagnosed from true epilepsy by the coexistence of other
hysterical symptoms and by psycho-analytic investigation which
of course dispels them if they are hysterical.
The hystero-epileptic fit, which is seldom observed in a patient
of British origin, almost invariably begins with an attack of an
epileptic character. Then follows an extreme form of opistho-
tonos in which the patient rests on the soles of the feet and top
of the head. After a pause the trunk is violently thrown back
on the bed: and this movement, rapidly alternating with opistho-
tonos, throws the patient up into the air many times in rapid
succession (‘‘ grandes mouvements”’ of the French). There
now follows a stage in which the patient strikes many
emotional attitudes illustrating joy, grief, terror etc. The
terminal stage is one of delirium in which many hallucina-
tions of vision are experienced. Of all this remarkable
display the patient remembers nothing except perhaps some
of the hallucinations. The ocular reflexes are retained as in
the hysteroid fit and the knee-jerk is present throughout in both
forms.
Hysterical fits are followed by a copious flow of watery urine.
This phenomenon is to be regarded as analogous to the increased
flow which occurs in certain emotional states, such as fear. It
is presumably due either to dilatation of the arterioles of the
kidney or to a rise in the general blood-pressure, resulting from
contraction of other arterioles.
Hysteria sometimes makes its appearance in the form of more
or less rhythmical spasms, the affected part of the body varying
in different patients. We meet with jumping arms and legs,
blinking eyebrows, salaams, hurried respirations, cough, hic-
cough, sniffs, grunts, barks and other strange noises difficult of
description. Such movements are commonly called “tics”’.
They are extraordinarily common and Dr. S. A. K. Wilson has
published a translation of a fair-sized volume on this subject
alone by Meige and Feindel. It iscalled ‘‘ Tics and their Treat-
y LO ee
HYSTERICAL PARALYSES 237
ment ’’ and is well worth perusal to-day, although it was written
in the pre-psycho-analytic era.
Catalepsy (flexibilitas cerea) sometimes occurs as an hysterical
symptom and somnambulism is, with some justice, regarded by
the French school as an hysterical manifestation. I have ob-
served spasmodic convergent strabismus in quite a number of
hysterical patients.
Hemiplegia is not very common, but it occurs. It is usually
associated with hysterical hemianesthesia.
Hysterical paraplegia occurs in several forms. When asso-
ciated with anesthesia of the legs, it is usually of the flaccid
variety. In other cases the legs are rigid (hysterical contracture).
In cases of the latter class of many years’ duration fibrous
adhesions may occur in the joints. The knee-jerks are greatly
increased and there may be spurious ankle-clonus. By spurious
ankle-clonus I mean a non-persistent clonus of which the first
contraction is an extension of the ankle pushing against the
physician’s hand, the first contraction of a true organic clonus
being an active dorsi-flexion of the ankle. Another feature of
spurious Clonus is that it cannot be elicited by tapping the tendo
-Achillis put on the stretch, whereas true clonus can be induced
this way. The plantar reflexes are absent.
Some patients are able to use all the muscles of the legs per-
fectly while lying in bed, but they cannot use them for standing
or walking (astasia-abasia). Astasia usually symbolizes an
unconscious desire ‘‘ to fall’’ in some sense, perhaps morally,
and abasia represents an inability “to go’’ in some sense—as
in the case quoted on p. 230.
Monoplegia or paralysis of one arm or leg, usually associated
with flaccidity and anesthesia, is another common manifestation
of hysteria. The paralysis is usually complete and it does not
involve any muscles of the trunk; such a condition cannot be
referred to an organic lesion.
The commonest hysterical affection of speech is “‘ stammer-
ing’’. This is sometimes consciously associated with a “‘ stam-
mering bladder’’ (in micturition), and we find on psycho-
analytical investigation that stammering is invariably associated
with unconscious difficulties of micturition and the castration
complex. The severest case I ever had (five words a minute)
had the severest castration complex I ever encountered, which
was traced to repeated stretching of the prepuce during the first
two years of life before deciding on circumcision. Such remarks
as “‘ It is too small”’ or “‘ It must be cut off’ have a profound
ce
238 MIND AND ITS DISORDERS
effect on the child’s mind, and I mention the case to warn medical
men against the practice of trying to stretch the prepuce instead
of circumcising the child immediately the prepuce is found to
be too constricted.
Hysterical aphonia (loss of voice) is very common. It is a
frequent accompaniment of a common cold, but it also occurs
independently of this as the result of shocks, frights and other
emotional disturbances. Hysterical mutism is a condition in
which the patient is unable to speak at all; he cannot utter a
single word, even feebly.
In all these paralyses the superficial reflexes of the affected area
are diminished orabsent. For example, the plantar reflex is usually
absent in hysterical paraplegia and the pharyngeal reflex in
hysterical aphonia, thus rendering laryngoscopic examination easy.
The organic reflexes are sometimes affected in hysteria. Some
patients suffer from difficulty of swallowing (dysphagia), others
from uncontrollable vomiting, a condition which may end fatally.
There is even an hysterical form of constipation, its peculiarity
being that it is not relieved by aperients or enemata, the bowels
being opened by suggestion only, and the constipation perma-
nently cured by psycho-analytical interpretation.
‘““ Spasmodic ’’ dysmenorrhoea and vicarious menstruation are
always hysterical, and not uncommonly amenorrheea is of the
same nature.
Fixation Hysteria.
Freud has given this name toa group of cases in which
the site of hysterical manifestation is determined by predis-
position of the affected part. If, for example, a person has
previously suffered severe traumatism in one arm, that arm is
lable to be selected as the site of subsequent hysterical symptoms.
Similarly, an organ possessing for the particular patient excep-
tional sexual value (for example, the eyes in the case of voyeurs
or peepers) 1s especially prone to hysterical affection, usually
blindness. It appears that, in this variety of hysteria, some
particular part of the body is already prepared to meet the
hysterical tendency half-way and to become, so to speak, the
“cat’s-paw ’’. Many cases of traumatic hysteria belong here.
Anxiety Hysteria.
In this variety of hysteria mental symptoms predominate.
The conversion symptoms most frequently associated with
anxiety hysteria are, in my experience, headache, amenorrhea,
ANXIETY HYSTERIA - 239
spasmodic dysmenorrhcea and dilatation of the stomach, with
or without visceroptosis and mobile kidney, but any of the
physical disorders mentioned under the heading of the anxiety
neurosis may occur.
The characteristic mental attitude is one of apprehensiveness
or anguish, so that many cases can easily be mistaken for melan-
cholia, so much so that sometimes the diagnosis cannot be
established until a preliminary psycho-analytical investigation
has been made. In asylums there are many cases of anxiety
hysteria which have been labelled “‘ melancholia ”’.
With some patients the apprehensiveness is more localized,
so to speak, and attached to specific situations. For example,
they are overcome by a sense of fear or anguish in open spaces
(agoraphobia), in confined spaces (claustrophobia), on heights
(acrophobia) or in crowds. There are many other situations in
which similar phobias may be induced, but it is convenient to
consider them in greater detail in the ensuing chapter, although
it must be admitted that most of the phobias belong here. Like
the symptoms of conversion hysteria, they are a form of com-
promise between unconscious wishes and corresponding repress-
ing forces, more or less conscious, but the formation of a definite
phobia appears to be a defence against conversion symptoms.
Most cases of anxiety hysteria are associated with a dilated
stomach. This is due to the adrenalemia of anxiety, which
inhibits peristalsis and closes the pylorus. The resulting fer-
mentation of the gastric contents leads to further dilatation and,
in some long-standing cases, a skiagram shows that the greater
curvature has dropped as low as the pelvis. Since the colon
hangs from the stomach (except for the costo-colic ligament at
the splenic flexure) the ascending and transverse colon drop too,
the former dragging the right kidney out of its bed (“ floating ”’
or “‘mobile’’ kidney). The gastric dilatation gives rise to flatu-
lence, and the visceroptosis causes backache.
Mental Characteristics of Hysteria.—Since every hysterical
symptom is the gratification of some unconscious wish or wishes
it is not surprising to find that the hysterical patient commonly
likes to cling to her symptoms and offers a very strong resistance
against recovery. There are all sorts of reasons why the doctor’s
advice should not be followed. The sounder the advice the
stronger the resistance, for the unconscious knows well enough
when it has met a real enemy. Symptoms occur at just that
time and place when and where they are most inconvenient and
will attract the greatest amount of attention; new symptoms are
240 MIND AND ITS DISORDERS
easily created by suggestion or by imitation of other patients
and, when the mere fact of being ill suffices to calm the mental
conflict, the patient resorts to self-mutilation of some kind or
something very like malingering in order to meet the situation.
A still more important characteristic of hysterical patients
is that their emotional reaction is excessive for some situations
and defective for others. They laugh and cry in the wrong
place, so to speak. The phobias of anxiety hysteria are a good
example of this condition. The patients fall into a state of
dread in some quite commonplace situation which stands in
their minds for some situation in which their fear, or a repressed
desire which it replaces, would be well justified; whereas they
remain unaffected and perhaps smile at a real danger. Take
the case, for example, of a patient of mine who had such a
morbid fear of stammering that he fell into a state of terror
whenever he had to give an order to one of his men, although
he had to be doing this all day long and every day for years.
Fortunately he was able to conceal this symptom so that nobody
had any suspicion that there was anything wrong with him;
indeed it was the offer of promotion to a more responsible position
which caused him to seek advice. On the other hand, this man
was rather entertained by an air-raid.
This peculiarity of hysterical patients is known as the “ trans-
valuation of values’’. It is not confined to cases of anxiety
hysteria, but is also a peculiarity of patients suffering from
conversion hysteria. Everything about them has a personal
interest and they become elated or, more frequently, take offence
at trivialities. They are liable to outbursts of anger or sullenness
and often refuse to state the reason for their behaviour. They
are egoistic, ever on the look-out for sympathy from others,
sympathy which feeds the disease, but which they take as their
right; and if they find it not, they will exaggerate their symptoms
and even make false statements in order to attract more attention
to their case.
Morbid Anatomy.—Lovell of Bethlem states that in anxiety
states the range of surface tension of the blood serum is lowered.
He correlates this observation with another, viz., that there is
deficiency of pancreatic secretion and, moreover, that in cases
of long duration there is a chronic inflammatory condition of the
pancreas to be found post mortem. It would appear probable,
seeing that the internal pancreatic secretion is the normal anti-
dote to adrenalin, that these changes are in some way related to
the adrenalemia constantly present in anxiety states,
HYSTERICAL INSANITY 241
Hysterical Insanity.—In some rare instances the above charac-
teristics influence the patient’s conduct to such an extent that
the authorities of hospitals and nursing-homes refuse to accept
further responsibility in the treatment. Under such circum-
stances the patient has to be removed to an institution for the
insane where, if carefully treated, she usually makes a good
recovery. Also, a few patients suffering from hysteria place
themselves under asylum care as voluntary boarders and some
of these subsequently have to be certified.
For instance, definite mental derangement exists during the
terminal stages of an hystero-epileptic fit and similar disorder
sometimes occurs without any associated convulsion taking place.
Such accesses occur in one of two forms:
(a) Hallucinatory delirium.
(5) Anterograde amnesia.
Generally they constitute the fourth phase of an attack of
hystero-epilepsy, but in some instances they may precede or
replace a convulsion.
In hallucinatory delirium the patient sees animals, visions of
God (usually symbolizing the father) or emotional incidents of
her past life. She is anesthetic except to the most powerful
stimuli, but is to some extent capable of perceiving the nature
of her surroundings. She weaves her hallucinations into them
and lives in a world of her own, not uncommonly she is living
over again some past emotional incident. As a rule there is an
abnormal amount of activity, but the patient can usually be
induced to recount what she sees. This dream state seldom
lasts more than a few hours and when it is over the memory of
it is usually incomplete.
In the attacks of anterograde amnesia, to which Pitres applied
the somewhat inelegant name “‘ecmnesia’’, the patient has
complete loss of memory for all events after a certain date, often
years back. As a consequence she thinks and acts as she did
at the age to which she has temporarily returned. These attacks
also rarely last more than a few hours.
Prognosis.—It is probable that a small number of the milder
cases of hysteria recover without treatment of any kind, but
the prognosis generally depends on the treatment (q¢.v.).. In the
great majority of cases the physician may look forward with
hope to effecting in a few months a cure which, in view of the
apparent severity of the symptoms, frequently causes much
surprise to the friends. Unfortunately, however, hysteria has a
16
242 MIND AND ITS DISORDERS
great tendency to relapse in home surroundings, but the tendency
decreases with advancing age. The duration of the disease does
not materially affect the prognosis provided there have not been
previous serious attempts at treatment which have failed. A
physician undertaking the treatment of a case of hysteria has
a heavy responsibility; for, if he fails to cure his patient, he thus
suggests that the case is incurable and makes subsequent attempts
much more difficult; for hysterical patients are pre-eminently ©
suggestible. Consequently, if a patient has already been treated
by neurologists and spent years in neurological hospitals, she
might almost be regarded as incurable because the suggestion
of incurability has been given in its most potent form.
Previous treatment by hypnotism and suggestion is, for some
reason or other, inimical to the success of subsequent treatment
by psycho-analysis.
It must not be forgotten that a few cases of hysteria end fatally,
especially those suffering from dysphagia, anorexia and vomiting.
Treatment.—Hysteria must be met on its own ground. As we
have seen, it is a purely mental disease and only mental measures
will cure it. Doubtless some very miid cases have been appar-
ently cured by the administration of iron to anemic patients,
of such appetizers as a mixture of nux vomica and nitrohydro-
chloric acid in anorexia, or of cod-liver oil, extract of malt and
such remedies when malnutrition is a marked symptom; but it
is probable that recovery is effected more by the suggestive
or mental effect of the medicines and their physical results than
by specific therapeutic action. Moreover, we must not forget
the mental influence of the doctor’s visits, especially if he is
fortunate enough to have what is popularly known as “a good
bedside manner ”’.
Many years ago Weir Mitchell introduced his well-known
method of treating patients by absolute rest in bed, isolation
from the outside world, systematized overfeeding, general massage
and faradic stimulation, with a view to increasing the patient’s
nutrition and putting on weight, wherein it was and is most
successful. Many patients recover from their hysterical symp-
toms under the treatment. Unfortunately, however, the cure is
but temporary in many cases. It used to be called the Weir
Mitchell treatment by isolation, but is now popularly known as
the ‘rest cure’’. The late Dr. Morton Prince, a pupil of Weir
Mitchell, used to tell us that the originator of the “ rest cure ”’
clearly recognized that suggestion played an important role in
the method. It now seems probable that this treatment is
TREATMENT OF HYSTERIA 243
nothing more than psychotherapy veiled by a complicated system
of disguise, and that every item of it acts by suggestion only.
Cognizance is taken of the fact that home influences are
inimical to the cure of hysteria. The patient is therefore sent
to a nursing-home, put to bed in a room by herself and allowed
to see nobody but the doctor and nurses attending her. She is
not allowed to do anything, not even to knit, sew or read, and
she must neither write letters nor receive them, nor is she to be
told any news from the outside world. The rest must be abso-
lute. In some cases it is recommended that the patient be raised
or lifted when necessary, as if she were helplessly paralyzed.
Dr. Weir Mitchell even went so far as to suggest that a bed-pan
should be used rather than a commode.
The next aim in the treatment is increase in the patient's
weight. This must be accomplished steadily and rapidly, so
that, each week when the patient is weighed, she is impressed
by the large amount of flesh she has put on.
The feeding is important. At first the patient must be induced
to eat a little more than has been her custom, together with a
glass of milk after each meal. The quantity of food taken at
‘each meal is then steadily and tactfully increased, extra glasses
of milk being given in the middle of the morning and afternoon
and at bedtime. Subsequently cream may be added, at first in
small quantities, later as much as 2 ounces in each glass of milk.
At the end of a month the patient should find herself taking four
good nutritious meals every day as well as 3 to 4 pints of milk
with 12 to 15 ounces of cream.
The nutrition is further increased by general massage for
twenty minutes, gradually extended to one hour, every morning
during the first two weeks, subsequently for one hour morning
and evening. The masseuse will naturally pay special attention
to those parts of the body in which the hysterical symptoms are
manifested.
Lastly, electricity in some form suited to the particular case
should be applied twice a day. For example, anesthetic parts
should be treated with the faradic wire-brush, the current being
of sufficient strength to penetrate the anesthesia at least in some
small areas; disturbances of motility without anesthesia may
be treated by judicious use of the ordinary electrodes; hysterical
blindness by mild galvanic shocks applied to the closed eyelids,
and so forth.
Hydrotherapy is often useful as a subsidiary method of treat-
ment in suitable cases, especially in the form of the cold shower
244 MIND AND ITS DISORDERS
and needle bath. In long-standing cases which have already
undergone many attempts at cure, original devices for impressing
the patient must be left to the ingenuity of the physician.
The latter should devote his visits to discovering signs of
improvement and letting the patient see them, without obtru-
sively pointing them out.
As recovery becomes established, massage, electricity, extra
milk and the general. régime should be gradually dropped and _
the patient allowed to return to normal life while under the care
of her nurses. Indeed it is well that she should go for a holiday
with one of them as a prelude to her return home.
It is best to avoid drugs; but it is, of course, necessary to
regulate the action of the bowels and to see that the patient
gets sufficient sleep. It is also sometimes desirable to give
before meals an appetizer such as nitrohydrochloric acid com-
bined with the tincture of nux vomica. The bromides are useful
in the treatment of patients suffering from hysterical fits, for
whom the general treatment of hysteria should be combined
with that of epilepsy.
Concealed suggestion may also be given by using some kind
of device for beguiling the patient into recovery. For example,
in a case of hysterical paralysis of one arm, a faradic battery may
be used, one electrode of which is placed between the shoulders
while the other is applied to the motor point of the biceps. The
patient is then told to bend her elbow. As soon as she makes
the effort the current is switched on so as to cause the biceps to
contract and flex the elbow, while the doctor says, “‘ Look ! you
are bending it—you see, you can do it—you will soon be cured ”’.
The arm electrode is then moved to another motor point, to flex
the fingers for example, and a similar procedure is carried out,
and so on all over the arm. Some patients can be cured at a
single sitting in this way. It must, of course, be left to the
doctor’s ingenuity to plan a combination of wiles, artifice, device
and manceuvre suited to the particular case he is treating. The
method was used successfully in many cases of traumatic hysteria
occurring among our soldiers during the War.
To suggest recovery in the waking state, after the manner of
Dubois and Déjérine, by demonstrating to the patient that he
is not suffering from any organic disease and that his affliction
is therefore purely mental, is not likely to achieve many good
results; yet I suppose that these authors must have met with
some success in view of the ponderous tomes they have written
about the method.
TREATMENT OF HYSTERIA 245
Suggestion in the hypnotic state is quite another matter.
Here the patient is in a much more receptive state of mind, and
many cases can be cured, even at a single sitting, under light
hypnosis. For example, a patient suffering from hysterical
astasia-abasia may perhaps be induced to walk hypnotized and,
if he be gradually awakened while he is still walking so that he
can observe his capabilities for himself, he has already trodden
the path towards recovery. Several further sittings may be
necessary to complete the cure; and this applies also to the other
modes of treatment above described. Even in the Weir Mitchell
treatment the daily visit of the doctor is an important item.
In any case suggestion consists of the imposing of the will of
the physician on that of the patient, but there is no attempt to
discover and eradicate the source of the mischief; hence we find
that many cases which have been cured by one of the above
methods relapse or develop new symptoms to replace the original
one and to fulfil its purpose.
The only radical cure for hysteria is to discover the unconscious
strivings which have given nse to the disease and, in so doing,
to reveal them to the patient. This procedure is none other than
‘psycho-analysis, to which frequent reference has already been
made. Its great disadvantage is that it takes an enormous
amount of time, so that no great physician can afford to treat
a patient by this method without more or less proportionate
remuneration. For the poorer classes a lengthy psycho-analysis
is therefore inapplicable; but the physician will always find his
psycho-analytic knowledge, if acquired by experience and not
only by reading, useful for helping such patients.
Mainly owing to the enormous fees of nursing-homes, a six
weeks’ “‘rest cure’’ is often as expensive as psycho-analysis.
In fact, the expense is but one more item of suggestion in Weir
Mitchell’s method. Moreover, this mode of treatment appeals
to the patient and his friends because it is of comparatively
short duration and gives the patient much less trouble. The
main objection to it is that which to a conscientious physician
is paramount—namely, that it is not a radical cure, while psycho-
analysis is. The latter is not necessary in every case, and the
best mode of treatment for any particular patient is to be decided
from experience, to discuss which would disproportionately ex-
pand this manual.
Lovell claims to have cured anxiety states by administering
secretogen in order to stimulate the pancreas.
246 MIND AND ITS DISORDERS
EXOPHTHALMIC GOITRE.
This disease in its fully developed form is characterized by
enlargement of the thyroid, protrusion of the eyes, tachycardia,
palpitation, tremor and mental symptoms. ,
It isa variety of anxiety hysteria with protrusion of the eyeballs
(exophthalmos) and enlargement of the thyroid superadded.
Etiology.—Exophthalmic goitre is four times as frequent in |
females as in males, and it occurs usually between the ages of
sixteen and forty. It is rare before ten and after fifty, but
Dreschfeld reported one case at the age of three and Divel
another occurring as early as two and a half years of age. Not
uncommonly it occurs in several members of the same family
and in such cases it is usually found that one or other of the
parents is neurotic or psychotic. The disease sometimes arises
as a sequel to influenza; but far more frequently the exciting
cause is found to be some mental shock such as fright, worry
or grief. Pregnancy is sometimes the cause; on the other hand
the symptoms are often ameliorated by the occurrence of preg-
nancy. The disease may be associated with hysteria, epilepsy,
chorea, and, as we shall see later, insanity.
Although this disease so closely resembles the anxiety neurosis,
as will be seen in the next section (which is exactly reproduced
from the second edition, in which I classified it among diseases of
the thyroid), it is rarely caused by exactly the same etiological
conditions as those of the anxiety neurosis. The usual sequence
of events appears to be (1) a fright, worry or anxiety induced
by some incident or circumstances which symbolize sexual
aggression; (2) partial or complete repression of the incident
or circumstances, whereby the fear is left unattached and there-
fore liable to attach itself to any transitory situation; (3) partial
or complete repression of the fear, which then finds expression
in the symptoms of exophthalmic goitre, which are nothing more
than the physical accompaniments or, as I think, bases of fear.
As examples I give a couple of juvenile cases, because they
illustrate unconscious early sexual symbolism before the patient
was in the least degree conscious of sexual matters or feelings.
A female child aged seven developed exophthalmic goitre as
the result of being frequently frightened by a black dog which
lived in the same street. Associations revealed that the black
dog symbolized a wicked man, “ black”’ meaning “‘ wicked ”
and “‘dog’’ signifying ““man’’, “‘ animal passion”’ etc. She
recovered.
EXOPHTHALMIC GOITRE 247
A girl of eleven, whose parents had died during her infancy,
was warned by a surrogate father that she should always make
sure, on retiring at night, that there was not a man under her bed.
As a result she used to go to bed in terror every night, but the
fear gradually extended into the day. At fifteen years of age
this dread disappeared and became replaced by exophthalmic
goitre or the physical signs of fear. It was the worst case I have
ever seen; indeed, she died six months after the onset.
Physical Signs.—The enlargement of the thyroid is as a rule
moderate and does not in itself greatly inconvenience the patient.
In some cases, however, it exerts some pressure on the trachea
and gives rise to cough and even dyspneea. It is usually pulsa-
tile; a thrill is sometimes to be felt in it and a hemic hum heard
with the stethoscope.
The eyehds are retracted, the palpebral fissure is widened
and the eyes protrude. All this gives the patient a staring
aspect. If, without moving the head, he transfers his gaze from
the ceiling to the floor, the upper lid lags behind so that a portion
of the sclerotic above the cornea becomes visible. Nictitation
is diminished in frequency. Convergence is weak and in severe
cases of exophthalmos there may be weakness of the external
recti so that double vision results on extreme lateral deviation
of the eyes.
The frequency of the pulse is greatly increased. A pulse-rate
of 120 per minute is common and this is easily raised to 140 by
slight exertion or emotional disturbance; even 160 is not rare.
Palpitation is a fairly constant symptom. Low blood-pressure
is the rule and probably accounts for those cases in which the
patient feels the pulse all over the body.
There is fine tremor of the limbs and trunk. It is best seen
in the fingers and especially when a good many muscles are put
into action, as when the patient stands, holds out her hands
and separates the fingers.
The patients are thin and in severe cases extremely emaciated.
They are weak and easily become fatigued on exertion, either
mental or physical.
The appetite is usually excessive. Often it is capricious, the
patient desiring to eat out-of-the-way, indigestible forms of food
such as lobsters, pickles and nuts. The saliva is scanty and
viscid and there is insatiable thirst. In some cases, on the other
hand, there is loss of appetite.
Diarrhoea and vomiting are common symptoms. These may
occur either together or independently of one another. Dresch-
248 MIND AND ITS DISORDERS
feld has shown that the vomiting of exophthalmic goitre is
associated with acetonzemia, acetonuria and air-hunger, such as
we see in diabetes. Asa rule the urine is otherwise normal.
It has been demonstrated of late that the basal metabolic
rate is enormously increased in all cases of this disease.
The patients feel hot and wear a minimum amount of clothing
even in winter. The secretion of sweat is increased and the
moisture of the skin thus caused diminishes its electrical resis-
tance, so that the muscles respond more readily to electrical
stimulation than in the normal individual. The knee-jerks are
brisk.
A good many “incomplete ’’ cases occur in which either the
thyroid enlargement or exophthalmos is wanting.
Mental Symptoms.—It has been pointed out by certain writers
that the above series of physical signs of exophthalmic goitre
is exactly the same as occurs in a normal person experiencing
the emotion of fear. This is the keynote to the mental symptoms
of the disease. Indeed, a well-known general physician of much
experience, who did not know my views respecting exophthalmic
goitre, once remarked to me, I think jocularly, that he had
noticed that nearly all the occupants of a tramcar during an air-
raid suffered from exophthalmic goitre.
A short period of irritability and restlessness usually precedes
the development of the physical signs and when these become
pronounced the patients are in a constant state of dread. As
every experienced hospital nurse is aware, any unusual incident
occurring in the ward, however trivial, even the placing of screens
round another patient’s bed, serves as a point d’apput for alarm.
When they receive a letter they fear that it may contain bad
news. Sometimes they are afraid that in telling the truth they
may bring some harm upon themselves or their family, and
they become untruthful. In other cases this fear leads to a
suspicious habit of thought. Their sleep is disturbed and they
are liable to wake up in a fright.
Sensation, perception and ideation are as a rule unaffected;
but hallucinations, usually visual, occur in a few cases. The
train of thought, judgment and reasoning are all normal and
the memory is good. The attention is apt to wander. The
patients are usually rather wilful; but their general conduct,
except in so far as it 1s influenced by the prevailing affective tone,
may be regarded as normal.
The above description refers to the ordinary mental state of
a patient suffering from exophthalmic goitre; but it has been
EXOPHTHALMIC GOITRE 249
long recognized that other psychoses are especially liable to arise
in the course of this disease.
Episodic Mental Disorders.—It is not surprising to find that
morbid fears and associated impulses are common among the
episodic mental disorders occurring in the course of exophthalmic
goitre. They differ from the obsessions described in the chapter
on the compulsion neurosis in that they are more variable. There
is no persistent agoraphobia; the morbid fear is liable to change
its character in the course of time, for example, to acrophobia,
fear of knives and so forth.
Mania and melancholia are also liable to complicate exoph-
thalmic goitre, the former being the more frequent, perhaps on
account of the diminished blood-pressure. Both states tend to
terminate in secondary delusional insanity, the patient develop-
ing delusions of persecution. I have also met with true paranoia,
tics, hysteria and hystero-epilepsy.
Morbid Anatomy and Pathology.—No changes of importance,
such as might suggest an unequivocal physical basis of this
disorder, have been discovered in the central nervous system.
Dr. W. S. Greenfield described changes in the sympathetic
‘ganglia of the neck, but these are not regarded as peculiar to
exophthalmic goitre. |
The thyroid is enlarged and unduly soft and it may contain
small cysts of colloid material. Microscopically it is found that
the secreting membrane lining the alveoli is hypertrophied and
thrown into folds and consists of columnar instead of cubical
cells. In conformity with this change the contents of the alveoli
contain mucin as well as colloid material. There is a deficiency
of iodine in the gland. In long-standing cases it becomes hard
and fibrous (toxic adenoma).
The thymus gland is hypertrophied, but normal in structure,
and occasionally it causes dyspnecea.
It has been suggested that the symptoms might be explained
by overactivity of the thyroid gland and consequent excessive
production of its internal secretion; but the disease cannot be
produced in most people by the ingestion of large doses of the
dried gland, although Boinet has recorded one case in which the
disease was caused in this way on two separate occasions and
was accompanied by mental symptoms (Rev. Neurolog., 1899).
It is not stated and probably not known whether the thymus
was enlarged in this patient.
Many of the symptoms, but not all (the tremor, for example),
can be explained on the supposition that there is excitation of
250 MIND AND ITS DISORDERS
the sympathetic system. This and many other considerations
rather support the view that this disease is purely psychical in
origin.
Prognosis.—Exophthalmic goitre has so many possibilities
that we have to be extremely guarded in our prognosis. Its
duration may be anything from a few days to twenty years or
more. On the whole the tendency is towards recovery, but
about 25 per cent. of the cases terminate fatally. The prognosis
respecting both recovery and the expectation of life is rather
more grave when episodic mental disorder supervenes. Of forty-
three such cases collected by Hirschl, only six recovered from
the mental disorder. Some cases terminate in myxcedema, even
after so short a period as two years. The possibility of inter-
current disease must not be forgotten; many of these patients
die of phthisis.
Treatment.—Almost every form of treatment has been tried
for exophthalmic goitre; each has had its successes and failures.
For some years the serum or milk of goats which have had their
thyroid gland removed has been successfully employed and
partial thyroidectomy has proved valuable in some early cases.
More recently the application of X-rays to the thymus has found
favour. Partial thyroidectomy and X-ray treatment relieve
practically all the physical manifestations, but they do not
entirely alleviate the mental symptoms, sometimes not at all.
One of the most striking results of the thyroidectomy is the
immediate reduction of the basal metabolic rate to normal. If
X-ray treatment gives no promise at the end of one month it
should be discontinued. Older remedies are the internal ad-
ministration of arsenic and painting the skin over the thyroid
with iodine.
The administration of small doses of iodine, either in the form
of potassium iodide (not more than I grain per diem) or Lugol's
solution (not more than 5 minims a day unless the patient is
under constant medical supervision) affords great amelioration;
but this is only temporary and the medicine is usually given for
three weeks in order to prepare the patient for operation.
The patient should live in good hygienic surroundings, prefer-
ably in the country. Mountain air is said to do good to some
patients. A liberal, plain, nutritious diet should be allowed. It
may be augmented by milk and cream and supplemented by
the administration of cod-liver oil and extract of malt. Bella-
donna proves to be the most serviceable sedative. Complica-
tions are to be treated on general medical principles.
EXOPHTHALMIC GOITRE 251
It must not be forgotten that these patients are easily fatigued
and that exercise is to be discouraged. est in bed is to be
enjoined during acute exacerbations of the disease.
Psycho-analysis reduces the pulse-rate practically to normal
in a month or six weeks, and the other symptoms are gradually
ameliorated in a few months; but my experience of this treat-
ment of exophthalmic goitre is at present too limited to justify
the suggestion that all other modes of treatment should be
scrapped in its favour. All my psycho-analytic cases occurred
during the War and the analysis had invariably to be given up
because the patients could not stand the air-raids on London
and went to live in country districts. I can confidently assert,
however, that so far its results were remarkably promising.
That the surgical procedure now in vogue (thyroidectomy) is
not always necessary is proved by the fact that a considerable
number of these cases recover spontaneously, just as other mild
hysterical cases do.
CHAPTER VI:
THE OBSESSIONAL NEUROSIS.
IRREPRESSIBLE THOUGHTS, FEARS AND IMPULSES.
‘ ,
THE name “ psychasthenia’’ was formerly applied to the con-
dition here described; but, since it has been used to include a
large number of symptoms which do not belong here, especially
by Janet and his followers, the name has been changed to “ the
obsessional neurosis’ or “‘ the compulsion neurosis ”’.
In the class of patients about to be considered the mental state
is such that some particular thought, feeling or impulse is so
uncontrollable and predominates to such a degree that it becomes
a real annoyance to the person possessing it.
This abnormal mental state is occasionally experienced by
perfectly normal people. To take some of the most frequent
examples: When we hear a catchy tune we instinctively sing
it over several times “in our heads’’, but occasionally this
process repeats itself over and over again in spite of every effort
being made to put a stop to it, so that the tune “runs in the
head ”’ for days or even weeks together. The same happens in
the’ case of catchy rhymes, the classical example being Mark
Twain’s
“Punch, conductor, punch with care,
Punch in the presence of the passengare.”’
It is instinctive in man to step over ditches, holes and such-
like gaps when he is out walking; and a burlesque of this instinct
takes place when he adjusts his steps to avoid walking on the
cracks between paving-stones. If during this process he should
by mischance happen to step on one of the cracks, he experiences
a certain amount of dissatisfaction. Yet why should he ex-
perience dissatisfaction when he knows perfectly well that it
does not matter ? And why should he put himself to all this
trouble when he well knows that it is unnecessary ? It is for
no other reason than that he cannot help it. An irrepressible
impulse was foiled.
252
OBSESSIONS 253
The instinct of the preservation of property is probably
responsible for a man getting up several times in the middle of
the night in order to make sure that he has locked the front-door
or that he has properly turned off the gas. The instinct of
secretiveness probably accounts for a man opening and re-
opening envelopes which he has addressed, in order to make
sure that he has not put his letters in the wrong ones. These
are examples of irrepressible fears occurring to normal indi-
viduals.
It is conceivable that even the above obsessions might develop
to such an extent that mentation could be no longer regarded
as normal. If the tunes or the rhymes became so persistent
that the man could not attend to his business or if he spent
all his nights going to and from the front-door or attending to
all the gas-taps in the house, his instincts would have become
such an annoyance to him that he would surely seek his medical
man for relief.
Obsessions are not the result of a Persistent emotional tone
and are not themselves persistent; they come in attacks. The
fears of impending harm experienced by melancholiacs are
- not obsessions, nor are the impulses of maniacs or patients
suffering from dementia precox. Perhaps the most important
difference between obsessions and the fears and impulses incident
upon other varieties of mental disorder is that in the latter
there is no attempt to control them, whereas in the former the
sufferer realizes the groundlessness of his dread, endeavours to
overcome it and, at least in the case of an impulse to do some-
thing wrong, tries to resist it. An obsessional patient fully
realizes that there is something mentally wrong with him, but
at the same time has the feeling that his particular obsession is
no part of his real personality. It is as though he were influenced
by something outside himself, but he is under no delusion about
the matter.
Etiology.—A history of neurosis in the patient’s family is
obtainable in about 60 per cent. of the cases. Physical ill-
health sometimes appears to be a determining factor. Apart
from this the disorder is invariably traceable to some incidents
in the patient’s past experience, which determine the nature
of the obsession.
Janet regards psychasthenia as a “ lowering of the psycho-
logical tension ’’, by which he means that the psychical response
of a psychasthenic to his environment is inadequate and less
than the normal so that his perception of reality is deficient.
254 MIND AND ITS DISORDERS
Observation and examination of these patients do not corrob-
orate this view; for not only is their perception remarkably
keen, but it is a curious fact that they usually belong to the
intellectual classes and not uncommonly possess exceptional
ability. |
Psycho-analytic investigation reveals that the essential etio-
logical factors of this psychoneurosis are always repressed or
forgotten situations or incidents of early infancy, the symptoms
arising usually by “‘ transference of the affect ’’ from an im-
portant unconscious thought to some related conscious thought
of little significance. Freud believes that such incidents invari-
ably have some sexual significance. My own experience confirms
this view in the majority of the cases; but I have analyzed some
of these patients to the extent of effecting a complete recovery
without discovering any sexual relationship. These have all
been cases of the morbid dread of heights, and it may be that
some sexual import might have been disclosed if the analysis had
been continued.
Irrepressible Thoughts.—These commonly take the form of
philosophical questionings arising from the instinct of inquisitive-
ness, such as: “‘ Is there a personal God ?”’ “ If so, who created
Him ?’’ ‘‘ Was there ever a beginning of all things ?” “If so,
did time exist before that ?”’ These questions constantly recur
and cause real mental unrest to the patient. Régis and Pitres
refer to a man who suffered mental anguish from the recurring
thought that the Kaiser or a president of a Republic had to
smile five hundred or a thousand times at a reception. Hack
Tuke recorded the case of a London undergraduate who was
constantly worried by the question where the word “not”
should be placed in a sentence containing it. These are a few
examples; there is, of course, no end to the thoughts that may
obsess such patients.
Irrepressible Fears.—For the sake of convenience a general
description of the commonest “ phobias’’ or morbid fears is
given in this place, but it must be understood that not all phobias
are symptoms of the obsessional neurosis. The same recurring
fear may in one patient be hysterical and in another obsessional.
The differential diagnosis is made during psycho-analysis, when
it will be found that the symptom is a compromise in the first
patient and a replacement in the second. In hysterical cases
the sense of fear or anguish is stronger than in obsessional ones.
Many of these irrepressible fears have received, perhaps some-
what unnecessarily, specific names.
PHOBIAS 255
The fear of dirt (mysophobia) which appears in many forms
is the commonest of all. Analysis usually reveals that dirt
symbolizes “dirt ’’ in a moral sense. Patients suffering from
this obsession are fairly comfortable so long as everything and
everybody near are still; but, should anybody be moving in the
room, they fall into a state of mental anguish lest some of the
dust raised by the movement should fall upon them or their
clothing. Some shake their clothing every few minutes. Others
avoid handling it, or any other articles for that matter; and
should such action become necessary, they wash their hands
afterwards. Consequently they wash fifty times a day or more
—a symbolic action also in many psychotic cases. Obsessional
patients are quite capable of appreciating the absurdity of their
actions and attitude of mind and they may often attempt to
resist the impulse to wash. A struggle between impulse and
reason ensues and they remain in that most distressing of all
emotional states, doubt, from which there is no relief for them
until the hands are washed. The appearance or knowledge of
the existence of a small piece of dirt of any kind causes them
mental anguish and is sure to lead to a fusillade of questions.
_ At the time when gas was the illuminant at Bethlem, one patient
required to know at lighting-up time what had become of each
match used for lighting the gas lest by some mischance a small
piece of the charred end might be floating about the ward and
ultimately come in contact with herself or her clothing. Not
content with the assurance that all the burnt matches had been
put in the fire, she would require a detailed account of what
would happen if they had not been put in the fire.
In another patient the disorder was initiated by her finding
a bug among her clothes. From that time she developed an
abnormal dread of coming in contact with such vermin. The
weekly change of bedding caused her much distress on account
of the possibility that a bug might find its way from the laundry
into her room. Such patients, if not looked after, will not
change their clothing from one year’s end to another.
Owing to the dissemination of medical knowledge by the lay
press in recent years the fear of microbes is becoming rather
common. When the microbic origin of cancer was on the tapzs
I had a patient who feared that she might have the cancer
microbe on her. Being of an altruistic nature, her main idea
was to avoid contaminating others. If a plateful of food was
placed before her, she took care to eat until the plate was clean.
She would rather eat fish-bones, nut-shells and egg-shells than
250 MIND AND ITS DISORDERS
run the risk of allowing any food touched by herself to come
into contact with others; and she suffered mental torture when
she was prevented from eating such refuse. Subsequently, of
course, her food was always specially prepared for her and all
inedible parts removed beforehand. |
The appearance of a cat causes mental anguish to some people.
One of our greatest generals, a man who knew no fear in the
presence of a death-dealing foe, suffered from this.
That hallucinations may occur in this disorder is obvious
from the fact that some of the patients see dirt, vermin etc.,
where there isnone. The following case is of interest on account
of the development of psychomotor hallucinations in association
with it:
The patient was an unmarried woman, aged twenty-eight, and
her illness dated from an occasion when some pieces of glass
froma broken lamp fell into the bath at her home. At first she
developed the fear that the glass might not have been all cleared
away and that some fragments might find their way into her
vagina. Then she feared that some insect might crawl there
during sleep and breed; especially she feared that she herself
might accomplish this end during sleep by unconsciously intro-
ducing hair or other material contaminated with microbes.
Psychomotor hallucinations then developed in which she felt
her hand move to her head and pull out hairs, although she saw
that her hand and arm were motionless by her side. She re-
covered after two years’ hospital care; but has since relapsed
and been cured by psycho-analytic treatment.
Agoraphobia or fear of open spaces is a condition in which
the patient suffers from a feeling of oppression, often accom-
panied by palpitation, cold sweats and tremors whenever he
passes into an open space such as a public square or field.
Claustrophobia is a state in which the patient suffers from
similar symptoms when he is in a confined space such as an
ordinary room or a railway-carriage. Acrophobia is an abnormal
fear of heights; nyctophobia, fear of the dark. Some people
have a similar sense of oppression when they are in a church
or a theatre, crossing a bridge or in a crowd. Stage fright is
a phenomenon of like nature. The insane fear of glass has
received the name crystallophobia.
There are some patients who suffer from the fear that an
organic reflex over which they have no control may occur in
awkward circumstances. The most common form of this
obsession is the fear of blushing (ereutophobia) on meeting
MORBID IMPULSES 257
strangers, the natural result of such fear being that the patient
does blush. Another common form is coprophobia, the fear of
evacuating the bowels when visiting other people or in a theatre
or at church (church diarrheea), the fear producing the dreaded
result. Stammerers and ticqueurs suffer from a constant morbid
fear of their stammer or tic. Here again the fear that they
should stammer or tic causes the symptom to manifest itself;
_ but these are hysterical rather than obsessional cases.
An insane dread of doing or having done some harmful action
is a common form of obsession. Such patients may fear that
they have destroyed something valuable. A clergyman was
compelled to visit all the communicants every Sunday afternoon
after he had administered the Sacrament, to satisfy himself that
he had not accidentally dropped some pins into the chalice
and thus caused them to be swallowed by communicants. The
same patient, if he had passed an open inkpot, would get the
notion that he might have pushed somebody into it. He realized
the absurdity of such an idea and resisted the temptation to
go back and look into the inkpot, but resistance was useless:
he suffered mental torture until he had gone back and satisfied
‘himself that there was nobody in the ink (insanity of doubt).
This case illustrates the relationship between the irresistible fears
and irresistible impulses mentioned below.
Irresistible Impulses.—Here we have to deal with states of
mind in which the patient feels impelled to perform certain
acts against his will. Arithmomania or the impulse to count
is one of the commonest; the patient may have to count ten
before he answers a question; he counts his steps, the number
of windows in each house he passes, the number of rungs on a
ladder etc.
There are people who are impelled to read every piece of
printed or written matter they come across, resist how they
will. If they go for a walk, they spend most of their time
reading posters of all kinds. If they see any person reading a
private letter, they are impelled to go and read it over his
shoulder. A man living in a suburb in the North of London,
anxious to free himself from this habit, deliberately avoided
reading a poster in the Strand on his way home from business.
He reached home and had his dinner; but the fact that he had
not read the poster haunted him to such an extent that, before
he could retire for the night, he was obliged to travel back to
the Strand, a distance of about seven miles, in order to obtain
relief from his mental unrest,
17
258 MIND AND ITS DISORDERS
Dipsomania is another form of the disorder. Like other
impulses it comes on in attacks during which the patient is
unable to resist drinking alcoholic beverages to an inordinate
extent, although he is anxious to abstain. Kleptomania is a
recurrent impulse to steal; pyromania, a recurrent impulse to set
things on fire, usually haystacks, heaths, commons and houses.
Some are periodically impelled to mutilate animals, especially
horsesand cattle. Others, again, are impelled to commit homicide |
orsuicide. Patients of this latter class usually present themselves
at asylums and mental hospitals as voluntary boarders asking
to be taken care of until the impulse has passed off.
It is curious that in the homicidal cases the patient is usually
impelled to kill his own children. In the case of a man who has
married a widow with children of her own whose livelihood
depends on the patient, he has no impulse to kill these. This
suggests that homicidal as well as suicidal impulses may be an
effort on the part of Nature to get rid of the unfit.
To sum up, the manifest characteristics of this form of mental
disorder are—
(1) Incessant recurrence of the obsession.
(2) Resistance which almost invariably proves to be useless.
(3) Mental anguish while the struggle between instinct and
volition is going on.
(4) Relief when, for better or worse, the struggle is over.
There is no disturbance of sensation in obsessional cases and
perception is normal except for the rare occurrence of hallucina-
tions. The judgment is sound, there are no delusions, the
patients have clear insight into their condition and there is no
disturbance of memory.
The conduct is normal between the recurrences, as also is
emotional reaction, and there is no change of temperament.
In other words, between the recurrences the patients are quite
capable of managing themselves and their affairs and of attending
to their ordinary duties. For these reasons it is not justifiable
to regard the obsessional neurosis as an insanity, any more than
neurasthenia or most varieties of hysteria and the anxiety
neurosis. A large number of people suffer from obsessions of
which they are ashamed. They kept them secret before the War
and none of their friends suspected that they had any mental
affliction; but conscription obliged them to declare their weak-
ness, especially if it disqualified them from fulfilling their military
obligations.
Insomnia sometimes occurs and may be troublesome.
TREATMENT 259
Except for some exaggeration of the tendon reflexes, there are no
physical signs known to be specially associated with the disorder.
Prognosis.—Left to themselves these patients seldom, if ever,
recover; and the prognosis is to be regarded as unfavourable
if the obsessions have lasted more than a year before the patient
comes under care.
The prognosis is, of course, much more favourable when the
patient undergoes psycho-analytic treatment, but some cases
prove extraordinarily difficult.
Pathology.—There is no morbid anatomy of the disorder. Its
psychopathology is that the affect of a repressed complex has
become detached and transferred to certain objects or situations
in conscious life, which symbolize such objects or situations; the
obsession representing a compensation or substitute for some
unbearable idea, which has been repressed, and taking its place
in a more tolerable form in consciousness.
The neurosis takes its origin from a conflict, during early child-
hood, between love and hatred towards the same person. This
begets, on the one hand, a mental habit of uncertainty, doubt
and weakness of will, and, on the other, an aggressive curiosity
(especially regarding sexual matters) which leads the child into
actions which he subsequently regrets to the extent of forgetting
(repressing) them altogether. In the ultimate analysis, anal
erotism and coprophilia are found to play an important role.
An obsession is a very great distortion of the repressed idea,
the distortion being effected, just as in dreams, by substitution,
displacement, ellipses, inversion etc. Moreover, the primary
‘obsession may in turn be repressed and replaced in consciousness
by a further distortion and so on. In such patients analysis
may be extraordinarily difficult. Other difficulties requiring
special technique, which need not be discussed here, are also
liable to arise in some cases.
Treatment.—It will already have been inferred that this
consists of psycho-analysis, which is the only cure. Repressed
complexes are unearthed and placed in their true light. In the
meantime there is no reason why these patients should not follow
their usual occupation.
Their physical health may be built up by the administration
of a good, plain, nutritious diet, plenty of rest during the day
and of sleep during the night.
Constipation, anzemia and such physical disorders should be
treated on rational lines, Maltine, cod-liver oil and the tonics
are useful adjuncts,
THE PSYCHOSES.
UNDER this heading are included :—
The maniacal-depressive psychosis;
Paranoia; .
Dementia preecox;
Paraphrenia ;
Epilepsy and its various manifestations; and
Alcoholism and other drug habits.
Like the neuroses and psychoneuroses, their basis is supposed
to be purely psychical, and such morbid anatomical changes as
have been described must be regarded as secondary; but, unlike
neurotic and psychoneurotic patients, the psychotic usually fail
to recognize their infirmity and therefore to adapt themselves to
their environment, except perhapsinanasylum. The psychoses
are the true insanities.
From the psycho-analytic standpoint, they differ from the
neuroses and psychoneuroses in that the infantile fixation is in
the very earliest years of infancy. And further that the mental
conflict is between the ego and the external world rather than
between the ego and the unconscious id. In dementia przcox
and in epilepsy the fixation is probably in the first few months
of life, in paranoia and paraphrenia during the second or third
years, in alcoholism a little later and in the maniacal-depressive
psychosis during the third or fourth year. It will, of course, be
understood that the fixation is affective, not intellectual; and I
give these dates tentatively.
The maniacal-depressive psychosis differs from the others in
that it is not a narcissistic psychosis. In this disease the mental
conflict is rather between the ego and the ego-ideal or super-ego.
CHAPTER VII.
MANIACAL-DEPRESSIVE INSANITY.
(INTERMITTENT AND PERIODIC PSYCHOSES.)
THE proposition that periodicity is a normal characteristic of
mental function is so self-evident that it scarcely needs ex-
emplification. The diurnal alternation between sleeping and
waking, the weekly day of rest provided by the Jewish law, the
200
INTERMITTENT INSANITY 261
monthly change in a woman’s character corresponding with her
menstrual period, the annual migration of man to the seaside
or elsewhere, which must be planned in every house of business,
and the alternating fits of energy and laziness normal to almost
every man and woman will at once occur to the reader.
The insane are not exempt from this law of periodicity. Every
form of mental disorder is liable to remission, intermission and
alternation; but the form of insanity about to be described is
especially characterized by remission and intermission or by
alternation and periodicity. The subjects are lable to attacks
of mania, melancholia or stupor, these being in some cases
accompanied or replaced by some delusional state.
The cases are divisible into two categories—
(a) Intermittent insanity
and (b) Periodic insanity.
Intermittent Insanity, which is the commoner of the two varieties
and, so far as the isolated attacks are concerned, the most curable
form of mental disorder with which we have to deal, accounts
for a large percentage of the admissions to asylums.
The mental equilibrium of these patients is unstable. Their
first breakdown occurs usually in the third decade and they are
liable to repeated attacks during the rest of their lives. The
intervals between the attacks vary in length: they may at
first be of five, ten or twenty years’ duration; but the intervals
tend to grow shorter as age advances, until at last the patients
require permanent asylum care. As the attacks get closer
together dementia supervenes, each attack leaving the patient
more weak-minded.
This form of insanity has been compared by the French school
to a spinning-top. So long as the top is undisturbed it main-
tains its vertical position; but a slight blow on the side sets it
swaying, the oscillations being at first comparatively slow but
becoming apparently more and more rapid as the sides approach
the ground; finally it falls on its side and rolls away. Its spin-
ning life is done, as is the mental life in the terminal stage of
intermittent insanity. But it is not always necessary for the
top to receive a blow in order to bring about its final downfall.
Left to itself, it will ultimately oscillate and fall to the ground.
So it is with all patients of unstable mental equilibrium; the day
must inevitably come, if they live long enough, when they have
a mental breakdown and become demented, no other cause being
assignable than their inherent mental instability.
262 MIND AND ITS DISORDERS
The first attack may be delayed until advanced age, but the
more unstable a patient is the earlier will be the incidence of
insanity.
Periodic Insanity is comparatively rare and differs from the
above form in that the intervals between the attacks are approxi-
mately of the same duration. The attacks themselves are ap-
proximately of the same duration and each is an almost exact
replica of a former one.
This state of affairs will be readily understood on reference ~
to the accompanying diagram, in which red represents mania or
some delusional condition, black represents melancholia or stupor
and the linear spaces represent intervals of sanity.
Periodic insanity does not tend to dementia to the same extent
as intermittent insanity. I have seen patients with recurrent
mania or recurrent stupor of many years’ duration, who suffered
from as many as twelve attacks in the course of the year but did
not show the least sign of dementia during the intervals of
sanity.
At any stage in the course of intermittent or periodic insanity
it may happen that either a maniacal or melancholiac stage
persists. In such cases the condition becomes one of chronic
mania or chronic melancholia.
The duration of the whole cycle in any of these states may be
two days to two years or more, and this remains the same for
each patient throughout the whole of life. One of my patients
has had an attack of depression every eleven years*—viz., at the
ages of nineteen, thirty, forty-one and fifty-two. Similarly, the
duration of any given phase remains the same for each patient
in each of his cycles. The various phases, however, of each cycle
are not necessarily of equal duration as represented for con-
venience in the diagram.
The transition from one phase to the other may take place
suddenly, slowly or by oscillation. In cases in which the duration
of the different phases is short, the transition is usually abrupt
and occurs at that important time in a man’s life, two o’clock
in the morning, when his temperature and vitality are at their
lowest, the time of onset of attacks of asthma and gout, the
time when the phthisical patient feels most miserable, and the
usual time of both birth and death.
In other cases the attack of mania or melancholia subsides
gradually during the course of a few days; but the patient, in-
* Since writing the above I have had two more such cases. Medical
psychologists will discern a possible basis for this number of years.
RECURRENT Manla.
RECURRENT MANIA
(Irregular Type).
RECURRENT MELANCHOLIA.
RECURRENT MELANCHOLIA
(Irregular Type).
ALTERNATING INSANITY.
ConTiINuous ALTERNATING INSANITY
CIRCULAR INSANITY.
(Two Types).
FIG. 33.—PERIoODIC INSANITY.
To face p. 262
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MELANCHOLIA 263
stead of recovering, as he apparently promises to do, becomes by
degrees more and more depressed or excited.
In yet other cases a melancholiac becomes excited for an hour
or so, then sinks back into his state of depression. He becomes
excited again, but for a greater length of time, and again he is
depressed. This process is repeated several times, the attacks of
excitement becoming longer and those of depression shorter, until
at last a definite attack of acute mania is established. The con-
verse may happen in the transition from mania to melancholia.
Etiology.—The essential cause of the disease is mental in-
stability, congenital or acquired. Congenital instability is
usually the result of defective heredity, ancestors of the patient
having suffered from mental disease, quite commonly from inter-
mittent insanity; but, as we have already stated, there are other
ways than heredity by which the parent may influence the child.
The Falrets, father and son, were able to observe three separate
families in which circular insanity occurred in the grandmother,
mother and daughter. Mott has published similar cases. Ac-
quired instability may be the result of alcoholism,* acute disease
or inanition. Exciting causes are mental and physical shock,
traumatism, gestation and parturition.
The root complex of this psychosis:is repressed sado-masochism,
a kind of self-punishment; but this will be considered more fully
under the. head of pathology.
MELANCHOLIA.
Melancholia is a phase of intermittent or periodic insanity,
characterized by a condition of misery in excess of that which is
justified by the circumstances in which the individual suffering
from it is placed, and by lack of energy owing to temporary
weakness of the muscles controlling the movements of the large
proximal joints. Kraepelin and his followers confine the use
of the word “ melancholia ’’ to cases of senile depression; but
such a limitation of the word is considered by the physicians of this
country to be unwarranted for reasons to be considered presently.
The several varieties may be classified according to (1) what
the patient does and (2) what he thinks.
if 176
Stuporose melancholia. Simple melancholia.
Agitated melancholia. Hypochondriacal melancholia.
Resistive melancholia. Delusional melancholia.
* In these cases the question arises whether the insanity and the alco-
holism are parallel indications of the same complex—repressed homo-
sexuality for example.
264 MIND AND ITS DISORDERS
Stuporose melancholia is characterized by defect or absence of
voluntary movement, agitated melancholia by excess of certain
movements, and resistive melancholia by active resistance to
attention and care by others.
Simple melancholia is characterized by the absence of delusions,
hypochondriacal melancholia by the existence of delusions con-
cerning the patient’s bodily organs and delusional melancholia _
by the existence of delusions concerning other matters. These
several varieties will be more fully considered after dealing with —
the symptomatology of melancholia in general.
Melancholia has its physical signs as well as its mental symp-
toms. The latter can be regarded as being dependent on the
former and are therefore considered first; but it must never be
forgotten that this psychosis is essentially psychical in origin.
Physical Signs.—The general health of the melancholiac is
bad. There is usually a history of loss of weight. His com-
plexion is rather muddy on account of an abnormal dryness of
the skin; the secretion of sweat and sebum are diminished, so
that the latter is apt to collect in little dry masses on the surface,
especially about the face. The hair is unnaturally dry and in
severe cases “‘ stands on end ’’, refusing to lie down in obedience
to the comb. The nails are brittle and inclined to spht. It has
been ascertained that the toxicity of the sweat is diminished or,
at any rate, not increased.
The patient is paler than when in health, partly on account
of a slight chlorosis, the red cells being a little diminished in
number and the hemoglobin more than proportionately dimin-
ished in amount. The specific gravity and the isotonic (osmotic)
power of the blood are lessened, especially in agitated melan-
choha.
The temperature is slightly subnormal and rather irregular.
The respiration is normal in frequency but shallow, while the
pulse is somewhat increased in frequency (80 to 100) and usually
feels weak to the finger.
Disturbance of the digestive tract is invariable. The tongue
is dry and coated with a white or brown fur and the patients
frequently complain of abdominal uneasiness. The latter is
largely an abdominal sensation of nervous origin, but there is
no doubt that it is partly due to indigestion. The gastric mucous
membrane, like the lingual, is dry and furred to such an extent
that in severe cases washings from the stomach are tinged brown.
The patient has no appetite; he loathes the very sight of food,
which may even cause pain or vomiting. Examination of a
PHYSICAL SIGNS OF MELANCHOLIA 265
“test breakfast ’’ shows increase of hydrochloric acid and de-
ficiency of pepsin in the gastric juice. The toxicity of the
gastric juice is greater than normal. Melancholiacs are invari-
ably constipated, partly from weakness (vide infra) of the ab-
dominal muscles and partly on account of deficiency of the
intestinal juices. Primarily it is probably due to repressed anal
erotism which is an important factor of the sado-masochistic
complex responsible for melancholia. Except when diarrhcea is
present, itself due to constipation, the feces are dry and hard
so that it occasionally becomes necessary for them to be digitally
removed from the rectum. Examination of the abdomen reveals
no physical signs of disease.
The quantity of urine passed by a melancholiac during the
twenty-four hours is diminished and its specific gravity is in-
creased before treatment; but the reverse is the case when he
is taking large quantities of milk and other fluids. There is
an increase of the earthy phosphates in the urine and a decrease
of the alkaline phosphates, of the sulphonates, of the total
quantity of nitrogen and presumably of urea since there is an
increase of urates and uric acid. The toxicity of the urine is
increased, especially in those patients who suffer much from
indigestion. This toxicity is possibly due to indoxyl, which is
often excessive in the urine of melancholiacs.
Contrary to the popular idea of melancholia there is as a rule
no abnormal secretion of tears; that secretion is diminished with
all the others. And when melancholia occurs as a sequel to
parturition the secretion of milk is diminished or arrested.
The generative function is disturbed in both sexes. Male
melancholiacs are usually impotent, probably because the
pleasurable tone of feeling associated with the sexual act is out
of harmony with their general feeling of misery. In females
amenorrhcea occurs during the acute stage of the disorder and
disappears as the patient recovers or passes into a condition of
chronicity. It is interesting to note the large proportion of cases
in which this amenorrhcea lasts nine months (the usual duration
of pregnancy)—probably a wish fulfilment.
The most important physical signs, however, which this dis-
order presents are referable to the nervous system. True head-
ache is not very common but patients frequently complain of a
sense of pressure on the top of the head (symbolizing repression).
It is rare for convulsions to be associated with melancholia,
and in those cases in which they occur they are infrequent.
Most striking and important among the physical signs of this
266 MIND AND ITS DISORDERS -
disorder of the nervous system are the motor disturbances. The
attitude and general appearance of the melancholiac are quite
characteristic. Sitting, walking and lying are uncomfortable
for him: he therefore stands. The head and trunk are inclined
forwards as in paralysis agitans and there is slight flexion of the
hips and knees. There is also slight flexion of the shoulders;
and the elbows, which are rigidly held to the side, are flexed to
a right angle. In cases of agitated melancholia the fingers are
in constant movement during waking hours, fumbling with the
buttons or picking holes in the skin of the fingers or face, picking
the nails or plucking the beard.
The facial expression is that of misery; the corners of the
mouth are turned down and the forehead wrinkled. The wrinkles
may be either transverse from contraction of the frontales or
Fic. 34.—-MELANCHOLIAC WRINKLING.
vertical at the root of the nose from contraction of the corru-
gatores superciliorum. These transverse and vertical wrinkles
may occur together in the same patient so as to give an appear-
ance which has been compared by French authors, not very
appropriately, to the Greek letter w.
The attitude and appearance above described are dependent
on rigidity, which is most easily observed and investigated in
severe cases of stuporose melancholia. The rigidity affects the
large proximal joints most and the small peripheral joints least;
for this reason I have called it “ proximal rigidity ’’ in contra-
distinction to “‘ peripheral rigidity ’’ such as occurs in ordinary
hemiplegia. The voluntary muscles of the trunk (especially
back and neck) are most affected, those of the shoulders and
hips to a less degree and those of the elbows and knees least.
The wrists, fingers, ankles and toes are usually free from rigidity.
Coextensive with rigidity, as in many other nervous diseases,
PHYSICAL SIGNS OF MELANCHOLIA 267
there exists slight paralysis (weakness) of the affected muscles.
Melancholiacs can rarely hold their arms vertically above their
heads and when they shake hands they do so from the wrist.
They walk slowly and from the knees rather than from the hips.
Fic. 35.—MELANCHOLIAC HANDSHAKE (LEFT).
The patients themselves state that they have “ difficulty in
doing things ”’.
The condition is one of slight double-hemiplegia: the bilaterally
acting muscles are therefore affected. Although ordinary reflex
Fic. 36.—MELANCHOLIACS SHAKING HANDS.
(medullary) respiration is unaffected, voluntary respiration of
cortical origin (taking a deep breath) is shallower than natural,
a symptom which sometimes causes the patient to believe that
he has “no breath’’; and here we should not lose sight of the
symbolic valuation of breath-—familiar to psycho-analysts.
268 MIND AND ITS DISORDERS
Melancholiacs have difficulty in showing their upper teeth; they
have to open the mouth widely in order to do so (I am here
referring to severe cases).
I have observed two ocular symptoms of this paralysis: one
is nystagmoid jerking on extreme lateral deviation of the eyes
and the other is weakness of accommodation. I have prepared
some very small test-types by photographing the ordinary test-
types for reading. Shortly after admission I make a note of —
the largest of these types which the patient is unable to read
and I find that, on recovery, he is able to read it easily, and
often a type two or three sizes smaller. Melancholiacs some-
times complain that near objects look larger than natural; this
naturally reminds us of the similar symptom in true internal
ophthalmoplegia.
I have suggested that the sensitiveness of the melancholiac
to noise is due to weakness of the tensores tympanorum, but this
must form a subject of future investigation.
Phonation is weak, lower pitched than in health and mono-
tonous. Similarly articulation is weak, the patient appearing
to his friends to be taking less trouble than usual in the pro-
nunciation of words.
In the less severe forms of melancholia speech is deficient and»
in melancholiac stupor absent. Even in mild cases of simple
melancholia it is an effort for the patient to join in a conversation
and still more so to originate one. Melancholiacs are slow in
reacting to questions, slow, as in all their actions, in answering
them, and their answers are as brief as they can conveniently
be made. There is no true aphasia, motor or sensory.
Writing, which is but another mode of speech, is similarly
affected. It is a trouble to melancholiacs; hence, in the acute
stage at least, it is slow and the calligraphy is so altered that
it resembles that of a child. All this is nothing more than a
special manifestation of the slight universal paralysis above
referred to.
The superficial reflexes (scapular, epigastric, abdominal, plantar
etc.) are all, as in hemiplegia, less marked than in health. The
plantar reflex is associated with a flexor response to the great toe.
During the acute stage the tendon reflexes are all diminished—
a feature which helps to differentiate this psychosis from anxiety
hysteria. The knee-jerks are equal and characterized by quick-
ness of reaction, both in the forward and backward movement,
especially in the latter. As a result of this the actual excursion
of the foot is small. If, in testing the knee-jerk in the acute
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FIG. 37..—FACSIMILE OF TEST-TYPES USED IN THE INVESTIGATION
OF MELANCHOLIA, BY WHICH IT MAY BE DETERMINED THAT
MELANCHOLIACS SUFFER FROM WEAKNESS—2.e., PARTIAL
PARALYSIS—OF ACCOMMODATION.
To face p. 268
MENTAL SYMPTOMS OF MELANCHOLIA 269
stage of melancholia, a finger be placed behind the knee the
semimembranosus tendon will be felt to spring into prominence
in apparent simultaneity with the tap on the patellar tendon.
Clonus never occurs. .
The electrical reactions of the muscles are normal.
Mental Symptoms.—Sensation is normal in a typical case of
melancholia. Peripheral analgesia may appear as a complica-
tion in a few cases. When it occurs, it is to be regarded as an
exhaustion symptom.
Perception is normal and the patient is able to understand
the nature of his environment. He cognizes objects and recog-
nizes people correctly. Except for lack of attention, to be
presently described, the appreciation of time and space is good.
The power of reviving a percept, of calling up a memory image,
in short, of ideation, is usually deficient and sometimes abolished.
For example, a woman suffering from severe melancholia is often
unable to picture the faces or to recall the voices of her children.
This would also appear to be due to the paralysis of attention,
since a greater amount of effort is necessary for ideation than
for perception. Hallucinations do not occur in uncomplicated
_acute melancholia, but some cases of chronic melancholia may
be complicated by hallucinations of hearing, the basis of such a
complication being presumably the explanation of the chronicity.
The psychical characteristics of melancholia can all be ex-
plained on the hypothesis that they depend upon the physical,
especially the motor, symptoms. The combination of an attitude
of general flexion and adduction, shallow respiration, constipa-
tion and:high blood-pressure gives rise to a feeling of depression
(vide the chapter on Emotion).
There is paralysis of volitional, instinctive and emotional
reaction. Accordingly the patient complains that his will-power
is gone, that he is unable to occupy himself as in the past. He
cannot bring his volitional attention to bear upon matters which
concern him, even when they are of the utmost importance. Such
is the paralysis of volition that even automatic acts, everyday
habits of life, may cease.
Similarly there is paralysis of emotional reaction. The
musculature has fixed the patient in an attitude of misery and
nothing will alter it. You may tell him the most excellent joke,
but he does not laugh; you may tell him that his favourite
daughter is dead, but he does not weep. He says that he cannot
feel such things now. This Joss of feeling, of which melancholiacs
complain, must not be confused with loss of sensatton—the
270 MIND AND ITS DISORDERS
difference needs only to be pointed out to the student to prevent
him from falling into this error.
In like manner instinct is paralyzed. The melancholiac has
no desire for outdoor games, for sociak or sexual intercourse,
or even for food. Not only is there paralysis of the instinct to
eat, but the patient also suffers from indigestion, due to his
constipation and apepsia. Under such circumstances it is no
matter for surprise that food is revolting to the patient and that —
he frequently refuses it altogether. He has no self-confidence,
his instincts of emulation and rivalry are gone. If he is a
collector of any sort of thing, he loses interest in his collection
and now suggests that he has wasted his life over it. He is
neither constructive nor destructive. In severe forms of melan-
choliac stupor the instincts of locomotion and of cleanliness are
gone; the patient stands immobile and may even be wet and
Name: Miss C. F., zt. 30 years. Disease: Melancholia,
March, April. May.
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dirty, but this is uncommon. Instinctive attention is paralyzed
and apparently, in a few cases, even reflex attention, so that the
patient cannot be startled.
The memory of melancholiacs is quite good except in so far
as they lack interest in and pay no attention to events going on
around them.
They have difficulty in getting to sleep; they awake unrefreshed
and their depression is accordingly worse in the early morning.
During the acute stage of their disease they have bad dreams.
Happy dreams are one of the earliest symptoms of recovery.
All melancholiacs are potential suicides, but some are so
suicidal that they are constantly on the watch for an oppor-
tunity to do themselves bodily harm; their life is devoted to
courting death and they require the closest supervision. Some
authors go so far as to classify such patients separately as cases
MENTAL SYMPTOMS OF MELANCHOLIA 271
of “‘ suicidal melancholia ’’, but this is not to be recommended
lest it should divert attention from the fact that all melancholiacs
are liable to commit suicide.
Most melancholiacs have good insight into their condition;
but if once they lose sight of the truth that all this enormous
wealth of symptoms is due to an illness, those very symptoms at
once become the premises for erroneous judgments; not that
they reason consciously about their symptoms, but that their
symptoms give them the feeling that such and such is the case
and, for no other reason than that they have this feeling, they
judge and believe it to be so. There is of course some sort of
subconscious reasoning about the matter.
They feel that their will-power, their emotions, their instincts,
their attention and their ordinary habits of life, all symbolic of
a living spirit within, have ceased. In other words, they feel
and therefore judge and believe that their soul is lost. Hence
arise the delusions that they are deserted by God, eternally
damned, have committed the unpardonable sin, are everything
that is vile and worthless, unfit to live and already suffering the
tortures of hell.
If they are animists, they think they are dead, non-existent or
“a little spot of black away in the distance ’’. A few patients
interpret the symptoms more materially and believe their brain
to be gone, a delusion which is fostered by a peculiar sensation
of numbness about the head.
Hypochondriacal melancholiacs, who are impressed by the
physical rather than the psychical manifestations of their disease,
complain of the weakness and sometimes of the stiffness. Some
say that they are paralyzed, a judgment which scarcely deserves
to be called a delusion; others go so far as to say that their legs
are made of glass or some such brittle substance and they behave
accordingly.
If it is the abdominal discomfort, due to indigestion and con-
stipation, which has most impressed the patient, he believes
that his bowels are obstructed, that they are on fire, that he is
about to suffer torture from peritonitis, that his throat is blocked,
that the food goes into his head, that his abdomen is distended
with food and that there is no more room inside, that he is filled
up with cancer, and so forth in endless variety.
The amenorrhcea of the female melancholiac gives rise occa-
sionally to the delusion that she is pregnant (the fulfilment of an
unconscious desire), and she accuses herself falsely of adultery
with some man towards whom she may in the past have con-
272 MIND AND ITS DISORDERS
sciously entertained tender feelings (again the fulfilment of an
unconscious wish).
Senile melancholiacs are liable to develop delusions of financial
ruin and to accuse themselves falsely of having led a reckless
life, of having failed to save money for their old age or of having
ruined their firm by falsifying the books. It is useless to show
them the books in order to demonstrate that all is well; nothing
will change their delusion. )
All the above patients attribute their condition to something
amiss with themselves; but there is another class of melanchohacs,
Fic. 39.—AGITATED MELANCHOLIA,
much smaller than the last, who ascribe their condition to inter-
ference by other people. These interpret their inability to do
things as due, not to their own weakness, but to an increased
resistance in their environment. They feel that they could
occupy themselves as they did formerly, were it not that their
occupation had been made more difficult for them. In this way
they develop delusions of persecution, they believe that other
people are against them, even that there are worldwide con-
VARIETIES OF MELANCHOLIA 4z3
spiracies to do them harm. This is one of the conditions which
used to be called ‘‘ acute paranoia’, a confusing term which has
fortunately been allowed to drop.
Clinical Varieties.—States of melancholia vary in degree, from
little more than a “ fit of the blues”’ to a condition in which
nearly all the symptoms above enumerated may easily be
detected; but apart from this there are several well-marked
clinical varieties.
Stuporose melancholia (melancholiac stupor, melancholia at-
tonita) is a condition in which the paralysis is so complete that
Fic. 40.—MELANCHOLIAC GAIT.
the patient neither moves nor speaks. Left to himself, he stands
silent and motionless in the same position, rigidly fixed in the
characteristic melancholiac attitude already described. Slight
cases of melancholia are usually mild examples of this class.
Agitated melancholia is a variety in which the patient, while
preserving the characteristic melancholiac attitude, is in con-
stant movement; this movement takes place, very naturally,
in just those parts which are least paralyzed, viz., the fingers
18
274 MIND AND ITS DISORDERS
and wrists, knees, ankles and, when not restrained by boots,
the toes. He paces about, walking, not from the hips, but
from the ankles and knees, wringing his hands, picking pieces
of skin from his fingers or face, or fumbling with the buttons of
his coat. These movements are usually accompanied by such
exclamations as ‘‘Oh dear! How dreadful! What a wicked
wretch I have been!’ and so forth. Craig believes the blood-
pressure is lower than normal in these cases.
Resistive melancholia is a variety in which resistance to the
usual attention and care is the most striking feature. It is a
rare condition. Most of the cases formerly classed under this
heading are now recognized to be katatoniacs.
Hypochondriacal melancholia, which may appear in the guise
of any of the above forms, deserves special recognition because
of its relatively intractable nature and also because of the special
proclivity of its subjects to suicide, generally with the idea of
calling attention to their case.
Melancholia may be said to have become chronic when most
of the physical signs of the acute stage have passed off, while
the patient remains in a persistent state of mental depression.
In some cases of delusional melancholia the physical and
mental attitude of misery pass away, but the patients are left
with a disordered judgment and retain their delusions. Such
cases might be designated “ melancholiac secondary delusional
insanity ’’. On the Continent it is called “‘ melancholiac secon-
dary paranoia ’’; but it is better to reserve the term “ paranoia ”’
for the condition hereinafter described as such.
Senile Melancholia.—With advancing age a man’s general
temperament tends to be more and more serious and tinged
with a constant feeling of depression as, little by little, he sees
all possibility of attaining the aspirations of his youth vanishing
away. When a man retires from business, his days of labour
being over, he sees that there is no more money coming in, has
visions of a penniless old age and hence becomes depressed.
Senile melancholia is possibly nothing more than an exaggeration
of this normal depression of old age; but my own impression
is that this would be correctly classed as a depressive stage of
maniacal-depressive insanity.
Kraepelin used to regard it as a separate disease of the in-
volution period and claimed apprehensiveness and restlessness
as its peculiarities, while he considered psychomotor retardation
and impediment of volition to be characteristic of maniacal-
depressive insanity. Moreover, the prognosis for intermittent
SENILE MELANCHOLIA 275
and periodic melancholia is good, while amelioration is not to be
expected in senile melancholia.
Now certain of these premises are erroneous, for apprehensive-
ness and restlessness undoubtedly occur in maniacal-depressive
melancholia, and psychomotor retardation and impediment of
volition undoubtedly occur in senile melancholia. Furthermore,
when maniacal-depressive melancholia recurs in senility or pre-
senility it tends to become chronic. Another point to be con-
sidered is that involutional melancholia is related by heredity to
maniacal-depressive insanity; for I have seen many instances
in which a parent has senile melancholia while the offspring
suffer from the maniacal-depressive psychosis.
Nevertheless, I am quite open to conviction in this matter, and
Farrar has so far accepted involutional melancholia as an entity
that he distinguishes three varieties:
Melancholia vera, with delusions of past wickedness and
consequent perdition of his soul;
Anxtetas presenilis, with delusions of immediately impend-
ing harm, verbigeration, rhythmical movements and sug-
gestibility ; and
Depressio apathetica, with mild depression and loss of interest.
Prognosis.—Leaving, therefore, the senile cases out of con-
sideration; unless the case has been improperly treated in its
early stages and has passed into a condition of chronicity before
being placed under skilled care, melancholia should always be
regarded favourably. The signs of chronicity are disappearance
of the physical signs without corresponding mental improvement.
If the digestion has become normal and the obstinate constipa-
tion has disappeared, if the urine is normal and the menstruation
regular, and if the patient looks physically in good health and
has become fat without corresponding mental improvement, the
case may be regarded as chronic. Other signs of chronicity are
the development. of hallucinations of hearing and, in women,
the growth of bristly hair on the face; but perhaps these are
indications that the diagnosis has been erroneous.
In the majority of cases, chronicity is reached or recovery
achieved within six months of the onset of the disease.
In a few cases the general nutrition of the patient is disturbed
to such a degree that death occurs as the direct result of the
melancholia.
There is no tendency to dementia in melancholia. Even
chronic melancholia need not always be regarded as hopeless.
276 MIND AND ITS DISORDERS
The author had one case of recovery (female) after eighteen years’
duration, and has had under his care one patient (male) who
had recovered from a previous attack of thirty-five years and
another (male) who had recovered from a previous attack of
seven years. One severe case of senile melancholia recovered
attemthrecwears, |
Treatment.—Improvement of the general nutrition is the key-
note of the treatment of melancholia. In order to attain this
result the patient must have—
1. Complete mental and physical rest.
2. A good, plain, liberal diet.
3. Careful supervision to prevent self-injury.
He must be put to bed and well fed.
The treatment of melancholia by rest in bed requires to be
insisted upon. By some misconception of the nature of the
disease a regrettably common notion has got abroad that the
melancholiac requires to be “‘roused’”’ out of his condition.
Before the War neurologists used to recommend “ travel’’, now
they prescribe “ distraction ’’; the result is the same in both
cases, for the patient is sent sightseeing.
And if he is sent to an institution for the insane I believe
I am understating the facts when I say that, in nine cases out
of ten, the chief endeavour of both doctors and attendants is to
make the patient occupy himself in some way or other: “ occupa-
tion ’’’ is the watchword in most asylums.
Now I say nothing against occupation for chronic patients in
good physical health; but to set a patient suffering from any
acute disease to work, merely because that disease has psychical
manifestations, is, I venture to assert, irrational. Even if it
be granted that occupation is good for the mind, it is obviously
wrong to disregard the enormous array of physical symptoms
detailed above.
Rest in bed is recognized as correct treatment for functional
or organic disease of any other organ than the brain. I have,
indeed, heard of a lay person recommending a patient suffering,
for example, from acute rheumatism, to “‘ walk it off’’, but not
of a physician recommending such treatment; but as soon as
the mind becomes disordered, the whole of the fundamental
principles of medical treatment are set aside and the patient is
worried to distraction.
Nature does what she can in the matter and suggests the
correct treatment by paralyzing the patient; and, if physicians
TREATMENT OF MELANCHOLIA 277
would adopt her suggestion, they would not only be doing a duty
to themselves by obtaining more satisfactory results, but they
would be also doing a duty to the community by reducing the
number of chronically insane.
This bed-treatment is no novelty. Griesinger recommended
it as long ago as 1865 and I am justified in my earnest advocacy
by its being now almost universally adopted in France, Hol-
land, Switzerland and Russia. I have observed the results
of both methods and it is my experience which causes me to
urge rest so strongly. Indeed we need scarcely any further
consideration than that the patient’s illness begins while he is at
his usual occupation, which he has selected as that for which he
is best adapted. In view of this fact, why on earth should
occupation, especially an untried occupation, be regarded as
treatment ? The answer is only too obvious.
Bed-treatment must not be shirked merely because there are
difficulties in the way. Surely the chief interest of our pro-
fession lies in the facing and overcoming of difficulties.
The first difficulty is that the patient objects to bed; but
every physician of experience knows that the melancholiac
objects to any form of treatment. A competent attendant soon
overcomes the objection by taking away the patient’s clothes at
the first opportunity. Some patients, by way of excuse, say that
bed makes them worse; but they alter their opinion in course of
time if the physician remains firm.
The second difficulty is that the patient either sits up in bed
and refuses to lie down, or he does not remain in bed at all but
stands by the bedside. Here again a tactful attendant can do
a great deal and his work may be lightened by the use of sedative
drugs. To young patients a couple of drachms of paraldehyde,
night and morning, give not only the desire for rest, but also a
certain amount of much-needed rest. In older patients half a
drachm or less of the liquor morphine bimeconatis three times
a day works like a charm. Tincture of hyoscyamus may also
be used with advantage in some of these restless cases.
The imsomnia must be combated by placing the patient in
circumstances conducive to sleep. The room must be quiet and
warm, but not stuffy; there should be sufficient bedclothes, but
not too many. When these measures are insufficient, a glass
of hot milk at bedtime often serves as a useful hypnotic. Fre-
quently, however, it becomes necessary to resort to the use of
drugs. j
There is a great multitude of hypnotics to select from, but
278 MIND AND ITS DISORDERS
they must not be used indiscriminately; the nature of the in-
somnia should be first ascertained.
When the patient is fairly somnolent, but liable to wake at
frequent intervals during the night, a good sedative at bedtime is:
Sodium bromide .. ae ae sf Af o's th aes
Tincture of hyoscyamus a a os libs
Water a ae ae ais "8 ~ ere ele
When the patient has difficulty in getting off to sleep, but re-
mains asleep if once started, the following is a good prescription:
Paraldehyde ‘ie oe Je - rau oye
Aq. menth. pip. .. wie 7 oe ad 3j.
If a more prolonged effect is required than can be obtained
by means of paraldehyde, amyiene hydrate, in doses of I to 14
drachms in an ounce of water, is strongly to be recommended.
At the moment of writing it is difficult to obtain this drug, but
two or three tablets of dial are a good substitute.
Sulphonal is not to be recommended for melancholiacs. It is
liable to accumulate in poisonous doses in the intestines on
account of the extreme constipation and to cause hematopor-
phyrinuria. Such a result is to be deplored, for many of the
patients suffering from this complication die within three weeks;
moreover, I have seldom seen a patient recover from mental
disease who has suffered from hematoporphyrinuria. Sulphonal
is a drug which is known to produce degeneration of the neuron,
and. it is in all probability this action which accounts for the
incurability of patients who have been poisoned with it.
The same remarks apply to trional. This drug is less liable
to cause hematoporphyrinuria, but more liable to cause neural
degeneration; so much that Soukhanoff, in his experiments on
degeneration of the neuron in animals, found that trional pro-
duced this effect more readily than any other drug.
Nevertheless I have seen good results from the use of both
sulphonal and trional in senile melancholiacs, who are less liable
to hematoporphyrinuria than younger patients. It may also
be remarked that males are less liable to this condition than
females.
As soon as the urine becomes tinged with red on account of
the presence of hematoporphyrin, the correct treatment is to
get rid of the accumulation of sulphonal or trional in the intes-
tines by obtaining a free action of the bowels and to administer
copious doses of lime-water, 5 ounces with an equal quantity of
milk every four hours.
HYPNOTICS IN MELANCHOLIA 279
The author’s experience of veronal, a drug which has been
much vaunted of recent years, has not been satisfactory. If the
insomnia is absolute and a sufficient dose of veronal be given to
procure sleep, it also induces vomiting on the following morning.
The drug is useful in milder cases. Medinal (sodium-veronal)
appears to be a better hypnotic and does not cause vomiting.
Enough has been said of physical rest; now with regard to
mental rest. The notion of giving the patient something to
occupy his mind is still much too prevalent. Patients are
given games to play, cards, draughts and even chess in order
to occupy the mind; or they are given odd jobs to do, with the
same object, and incidentally to relieve the attendants.
Now I hope that no words of mine will serve to increase un-
necessarily the already too heavy labours of attendants on the
insane. But the attendants can hardly be said to be relieved
when the result of this treatment is a prolongation of the acute
stage of the patient’s illness or the conversion of an ordinary
melancholiac into a heavy nursing case. It may be argued that
occupation gives the patient something else to think about.
Verily it does give him “ something else ’’ in the sense of “‘ some-
thing more’’ to think about; but his mind is concentrated on
his own wretched condition as well as his occupation. As to
the games, can anything be more incongruous than to allow a
patient who requires mental rest to play chess ? Chess at least
should be contraband of acute insanity.
By all means let the convalescent and chronic patients assist
the attendants or play games; but let not patients in the acute
stage of mental disorder be treated by worrying the very organ
which is affected, lest it lead to permanent mental disablement.
It is sometimes argued that the patient must think of some-
thing, and it is best that he should not think of his own mental
troubles. I cannot agree with this view. The amelioration of
the insane is already far advanced if they have been induced to
believe that their state is one of illness and that the illness is
curable; and nothing will impress these facts upon them more
than to make them lie in bed and do nothing, just like any
ordinary hospital patient, and to see that the doctors and atten-
dants are doing their very best to procure their recovery.
Nourishment.—One of the most important instruments in the
armamentarium of any institution for the cure of melancholia is
a weighing-machine; and the feeding of the patients must be
so adjusted that the machine shows, week by week, a steady
increase in their body-weight. This fundamental principle in
280 MIND AND ITS DISORDERS
the treatment of mental disorder has been called the “ gospel of
fatness’. Patients must be fed on a good, plain, nutritious diet,
without excess of nitrogenous constituents.
If a patient fails to increase in weight, extra food should be
insisted on. The form which this extra diet takes must be left
to the discretion of the physician. The writer is in the habit
of recommending three extra pints of milk, with or without the
addition of cream. Other useful adjuncts are a mash of bananas
and cream after dinner, a cup of hot cocoa at bedtime, and
chocolates.
Cod-liver oil may be strongly recommended, not the nasty,
oily, indigestible, yellow product, but the old-fashioned brown
fishy oil, from which the jecorin and other digestive constituents
have not been removed by refining processes.
Care must be taken not to carry this overfeeding to excess
lest it defeat its own object by upsetting the patient’s digestion,
making him sick and rendering food even more objectionable to
him than it was before.
Food may be made a little more pleasant by giving the patient
an appetizer a quarter of an hour before meals, such as:
Dilute nitrohydrochloric acid “ oe Perera |i
Tincture of nux vomica .. ote ee oe “Tie
Syrup of orange (or the tincture with gluside) .. 3j.
Compound infusion of gentian.. ov to 3}.
A glass of port with dinner serves as a useful digestant.
It is also to be remembered that these patients suffer from
apepsia, they may therefore be allowed a small dose of liquor
pepticus immediately after meals. Soured milk given for a fort-
night at a time proves an excellent corrective for the digestive
troubles, and it improves the patient’s general nutrition at the
same time. It acts best when given with a vegetarian diet.
Alcohol and drugs must be avoided while the patient is under-
going a course of this treatment.
For various reasons melancholiacs at times refuse to take
sufficient nourishment to increase their body-weight. This may
occur even among convalescents, who become anxious about their
previously slim figures. With the latter class those in attendance
upon the patient should tactfully fail to observe any notable
increase in the patient’s rotundity.
All too frequently, however, refusal of food is a persistent
symptom, which can be combated by forced feeding only. As
soon as the patient ceases to put on weight, there must be no
quarter; it becomes the duty of the attendants to force with a
TREATMENT OF MELANCHOLIA 281
spoon the last portions of each meal upon him; and if the resist-
ance is so active that such measures fail, it is necessary for the
patient to be tube-fed.
Massage and gentle faradism are also to be recommended as
further aids to nutrition. The massage, which is most advan-
tageously carried out between ten and twelve in the morning,
should be general or at least employed for the neck and shoulders,
spine, hips, thighs and abdomen. The faradism, which should
be stimulating but not too unpleasant, should be applied to the
same areas with the exception of the abdomen.
The constipation of melancholia is often very troublesome to
treat. For the treatment of this symptom the reader must refer
to works on general medicine; but he should remember that
melancholiacs, and the insane generally, require stronger purga-
tives and larger doses of them, than constipated members of the
sane population. It is frequently necessary to resort to copious
enemata of soap-and-water. The writer often employs the fol-
lowing compound enema for his patients, who find it both
effectual and comforting:
Olive oil be ee ar ss “. vary A) Sa
Castor oil .. sie Ye oe ste 2. ij.
Glycerine a ae yt ate a, AI.
uEpentine .. ae oe tt ae Fe | ag:
Digital evacuation of the rectum is occasionally necessary. I
have had excellent results from hormonal, a drug introduced for
constipation some years before the War, but at present unobtain-
able, so far as I am aware. The injection of a single dose
into the gluteal muscles cures constipation for at least some
months.
When the patient’s nutrition begins to show signs of consider-
able improvement he may be allowed to get up, at first for a
few hours in the evening, bed-treatment being then gradually
reduced.
During this period of convalescence he may begin open-air
exercise in the form of drives or short walks; and, while he is
indoors, occupation, games and entertainments all make for
recovery. Should he show any signs of relapse, he must be
sent back to bed for further treatment.
Prevention of Suicide and Self-Injury.—Patients must be
deprived of all means of doing themselves bodily harm. Poison
and firearms are, of course, absolute contraband of lunacy.
Knives and scissors should be under lock and key and the atten-
282 MIND AND ITS DISORDERS
dant in charge of such articles should know exactly how many
there are. On each occasion when they have been used they
should be re-counted in order to ascertain that none are missing
before locking them away again. Similarly medicines should
always be under lock and key.
The rooms in which the nursing is carried out should be free
from projections liable to serve as possible conveniences for the
patient to hang himself. Gas-flames and fires in the room should
be protected by strong wire guards. The patient should not be
allowed a handkerchief at night lest he strangle himself with
it under the bedclothes; nor is it permissible for him to wear
sleeping garments made of any substance which may be torn
noiselessly, e.g., flannelette, lest he use a strip for purposes of
strangulation.
Melancholiacs, at least those who are actively suicidal, should
be under constant observation and have no opportunity of
secluding themselves. It should be impossible for them to
obtain possession of any keys, and there should be no bolt to
the door of the w.c.
Constant supervision is the best safeguard for suicidal patients;
but, even under the most careful observation, they contrive at
times to do themselves injury. A chance cup of boiling tea
suffices to produce a fatal cedema of the glottis, a secreted hairpin
may serve the purpose of a dagger or a sudden dive from the
height of an ordinary chair may fracture the base of the skull.
It speaks volumes for the attendants on the insane that suicides
are not more frequent in asylums.
Occasionally it happens that the physical signs, so far as
our crude methods of examination are able to detect, pass away
and the patient gets fat and apparently well in physical health,
without corresponding improvement in his mental condition.
This is especially hable to happen to patients who have just
passed through an attack of acute mania. Physical health has
been restored apparently to perfection, but the mental improve-
ment “‘ o’erleaps itself and falls on the other ’’’, and they become
depressed. If, after a further course of treatment on the lines
above recommended, the patient remains persistently depressed,
what is to be done ?
It has been observed that some such patients make a rapid
recovery after an attack of acute physical illness, e.g., erysipelas.
Accordingly it has been recommended that an acute physical
illness should be induced and the illness which has been selected
for the purpose is hyperthyroidism. The patient is put to bed
HYPERTHYROIDISM FOR MELANCHOLIA 283
and treated for a week with thyroid gland, conveniently in the
form of tabloids. During the course of the
First day, he takes 30 grains of gland—6 5-grain tabloids
Second ,, a 40mm inf Seyi} nf
Abird a Ciar y 7, LO Sade, rs
Fourth ,, ss GOaves iP Daas »
Batth 7. Af GG) arp es bie to FA ys
Sixth Ai yy 40 oo ” 8 5- ” ”
Seventh _ AO tags; ” Oates ”
at suitable intervals. His temperature should be taken regularly
and the pulse carefully watched. Slight rises of temperature
are unimportant, but irregularities of the pulse should be treated
with digitalis and strychnine. Patients with a small thyroid
must be treated with smaller doses of the gland. The patient
loses 5 to 10 pounds during the treatment, sometimes improves
mentally, but more often deteriorates. Towards the end of
the week he begins to look physically ill. The ordinary treat-
ment of melancholia is now started de novo and in quite a satis-
factory proportion of cases the end justifies the means. The
patient passes through a short stage of convalescence and finally
recovers.
MANIA.
Mania is that phase of intermittent or periodic insanity which
is characterized by a condition of excitement or exhilaration in
excess of that which is justified by the circumstances in which
the individual suffering from it is placed and by disproportion-
ately excessive activity of the movements of the large proximal
joints.
Four varieties have to be considered, viz.:
Simple mania.
Acute mania.
Acute delirious mania.
Chronic mania.
Mania, like melancholia, has both physical signs and psychical
symptoms, the latter being possible of explanation on the hypo-
thesis that they are dependent on the former. The physical
signs of the several varieties of mania differ in degree only, but
they are most characteristic in acute mania.
Physical Signs.—Although the maniac persists, as a rule, in
maintaining that he is in excellent physical health and feels
well, strong and virile, his general health is in reality far from
good.
284 MIND AND ITS DISORDERS
There is usually a history of loss of weight; he looks ill and
pale and is perhaps anemic. The tongue is furred, the appetite
poor and the bowels constipated; but these signs are not so
marked as in melancholia, for the maniac at times eats vora-
ciously and the bowels may act regularly.
There is an increase in the quantity and amylolytic power of
the saliva and an increase of hydrochloric acid in the gastric
juice, which has been found to be more toxic than normal.
The pulse is frequent, but not as a rule disproportionately
frequent in relation to the patient’s motor activity. There is
Fic. 41.—ACUTE MANIA.
slight chlorosis and the toxicity of the blood is increased. The
temperature 1s normal, except in acute delirious mania.
There is increase of nearly all the secretions. The sweat is
abundant and is said to possess a ““ mousy ’’ odour. In puerperal
cases the secretion of milk is increased and liable to cause trouble
by tending to the formation of mammary abscesses.
The quantity of urine is increased and there is an augmenta-
tion of the total quantity of solids which it contains. Injected
into animals the urine of maniacs is said to cause local spasms,
hypothermia and mydriasis.
In women menstruation is irregular in time and in quantity,
but it is rarely suppressed as in melancholta.
PHYSICAL SIGNS OF MANIA 285
Signs of disorder of the nervous system are, however, most
important of all. General hyperesthesia, which will be subse-
quently considered, is the rule.
There are no paralytic symptoms and no rigidity. On the
other hand, the most characteristic feature of acute mania is
great motor excitement. A rather coarse tremor of the hands
and face occurs in some Cases.
Observations on movements of the insane in general, and of
maniacs in particular, are best made on female patients in the
Fic. 42.—ACUTE MANIA.
garden; because females react more readily than males to ordinary
stimuli, and movement is less restrained in the open air.
The movements of a maniac in a state of motor excitement
take place for the most part in the large proximal joints. The
trunk sways freely as the patient walks, and when he runs, there
is exaggerated movement at the hips. In the waving of the arms
which is common in mania, the greatest movement takes place
at the shoulders and there is little movement of the hands and
fingers. The maniacal handshake is from the shoulder and the
286 MIND AND ITS DISORDERS
maniacal attitude of prayer is with hands upraised to heaven;
whereas the melancholiac attitude of prayer is with hands
clasped in front of the sternum. The typical attitude of the
maniac is with the elbows abducted from the side, while that
Fic. 43.—MANIACAL HANDSHAKE.
(Drawn from a photograph.)
of the melancholiac is with the elbows close to the side. It is
interesting to correlate this observation with the results obtained
from normal people with the automatograph (p. 55).
The superficial reflexes (scapular, gluteal, cremasteric and
plantar) are exaggerated. Stroking the sole of the foot elicits
MENTAL SYMPTOMS OF MANIA 257,
a flexor response of the great toe. The tendon reflexes, e.g.,
knee-jerks, are usually diminished during an attack of motor
excitement but may be exaggerated during a period of rest.
Mental Symptoms.—In the course of an attack of acute mania
two stages have to be recognized: the stadium acutum and the
stadium debilitatis. The mental characteristics of. these must be
separately considered.
In the stadium acutum there appears to be augmentation of
all modes of sensation. Patients in this condition are sometimes
able to hear every word of an ordinary conversation fifty yards
Fic. 44.—MANIACAL HANDSHAKE.
away, provided they are undisturbed by other sounds; and I
have known a patient call my attention to the ringing of church
bells which could only just be heard by myself, and were quite
inaudible to a neighbouring attendant. Similarly, if the point
of a pin be lightly applied to the patient’s skin, he starts or
screams. Faint odours also are easily detected by acute maniacs.
These symptoms are of importance in the differential diagnosis
of mania from other states of excitement.
Perception is normal and often extraordinarily keen, and the
medical officer usually hears a few home truths from these
288 MIND AND ITS DISORDERS
patients on his morning round. Hallucinations and illusions do
not occur, except as a rare complication of the malady.
The maniac has deficient control of his emotions; he laughs,
cries or grows angry for little or no reason. Similarly he has
deficient control of his instincts; he is erotic, in some cases to
such an extent that modesty is lost, but this is unusual. He
collects rubbish systematically, hoards up old newspapers and
stores away useless odds and ends with fantastic tidiness. He is
at once constructive and destructive; he tears up an old garment
with the intention of converting it into a new one, but the
renovation never takes place.
The instinct of self-adornment is exaggerated; simple maniacs
adorn themselves with flowers, brilliantly coloured ties and
perhaps grotesque hats; mild cases of acute mania decorate
themselves with leaves and wear pieces of string on their fingers.
Other patients, more severely afflicted, may perhaps tear the
coloured borders off their blankets and swathe themselves
fantastically to represent gypsies or Zulus. The instinct for
mischief and practical joking is augmented. Ornaments are put
on the fire, the gas is blown out and the room turned topsy-turvy
for fun. The instinct of noisiness is exaggerated; the patients
scream, shout and sing. Their uncontrolled activity gives them
an illusive sense of well-being and they may hence become
boastful and exalted about their capabilities.
Some such patients feel ready to defy death; a dangerous
symptom, since it may lead them to commit suicide by accident.
‘‘ There with fantastic garlands did she come
Of crow flowers, nettles, daisies, and long purples,
That liberal shepherds give a grosser name,
But our cold maids do ‘ dead men’s fingers’ call them;
There, on the pendent boughs her coronet weeds
Clambering to hang, an envious sliver broke;
When down her weedy trophies, and herself,
Fell in the weeping brook. Her clothes spread wide;
And mermaid like, awhile they bore her up:
Which time, she chanted snatches of old tunes,
As one incapable of her own distress,
Or like a creature native and indu’d
Unto that element: but long it could not be,
Till that her garments, heavy with their drink,
Pulled the poor wretch from her melodious lay
To muddy death.”’
Maniacal patients are incapable of sustained volitional atten-
tion; but instinctive attention is easily aroused, any chance
percept serving to divert the current of their thoughts. In
CONDUCT IN MANIA 289
this way arises one form of incoherence. If, for example, a
maniac be talking of his state of health, the rattle of keys will
at once turn his conversation to the subject of keys, and so forth.
Similarly, a word may suggest others rhyming with it; a hat laid
on the bed may set him talking in this wise: “‘ That hat, cat, rat,
bat” etc., the chance sound claiming instinctive attention.
Association of ideas is very active with these patients, their
ideation flowing more rapidly than normally, and more rapidly
than words can be uttered to express them (“ flight of ideas ’’).
This symptom gives rise to another form of incoherence, in
which connecting-links in the train of thought are elided. In
the following example, quoted from a police-report, it is possible
to supply the links in some places, but not in others. Probably
it is not a case of mania, but it is a good example of incoherence:
‘“ IT have got millions of money and am going to Windsor. I went
to heaven yesterday and it was very dark. My mother and
dead relations welcomed me and I went out with them. The
Lord said to me: ‘ You are the Holy Ghost; the Trinity is now
complete’. I was born every evening and came here on the
third. They said I was mad, but I was not. All the money I
got I gave to the Lord and had not a penny left. I was with
some of the finest men, you know. I shall have France, and
Russia as well, and there will be one God from north to south.
We call this the Green Island and the Green Moon, and England
will be called the Rose Moon. There will be ever so many more
moons, and that is the explanation of all these little stars. I want
a few millions, and I will make a millon—ten millions—to-day.
But I cannot move without the consent of the Queen to marry
me. Every man will have as many wives as he likes. The Lord
told me the reason, and there will be no more doctors. I shall
have a thousand of the most beautiful women, and if a man takes
a fancy to any of them he will have to pay me what I like, and
all the money will go to the benefit of our glorious Empire.
You should have seen how pleased my mother was. Every
morning at half-past five all the little children were examined
by God. I can read a man’s character well. I can read yours.
You are a very honourable gentleman; I know almost every
incident in your life. I’m just going to Windsor now. Will
you gentlemen have a silver moon luncheon with me? Charlie,
old fellow, here is £5,000 for you. George, I will make a Cabinet
Minister of you. I have been honourable to my foster-sister.”’
The memory of maniacal patients is good.
The insomnia of mania differs somewhat from that of melan-
Tg
290 MIND AND ITS DISORDERS
cholia in two particulars. In the case of a melancholiac the
number of hours of sleep during each night remains fairly con-
stant; in the case of a maniac the number of hours is extremely
variable as shown in the accompanying chart. Further, what
little sleep there may be in mania occurs during the earlier
hours of the night; in melancholia it occurs during the later hours.
Most maniacal patients have good insight into their condition;
but if they lose that insight delusions at once arise, usually as a
result of the feeling of power given by abnormal stimulation of
the cerebral cortex.
Maniacs have a feeling of increased will-power and hence
believe, in some instances, that they can influence the will of
others. Such patients will stare at others in the belief that they
6
are ‘‘ willing ’’ them to perform certain acts. They will tell the
Name: Miss A. A. R., zt. 24. Disease: Acute Mania,
March. April.
stot te fe eee allel sale lsieiele be [eal ie fief] efer
a atlas BREEN PES
i i He
uA | Hi
ys
~
Hours or Steep
}
2
5
4
5
6
Ch i
8
9
doctor that they are curing other patients by will-power. Some
believe themselves to be lords, dukes, kings, God Almighty or
possessed of untold wealth.
The speech of acute maniacs is commonly incoherent for reasons
already considered. Articulation is normal.
The writing is also incoherent; the calligraphy untidy, irregular
and besmirched with blots. The first line may be written at the
bottom of the page, the paper is then turned upside down or
sideways and another line written and so on until the page is
nothing but a tangled mass of words.
The second stage of acute mania is one of exhaustion, “ calm
after the storm’”’, the so-called stadium debilitatis. After the
stage of excitement has subsided the arms fall to the side and the
patient sinks into a condition of stupor. He has analgesia of
the arms, forearms and hands, as well as of the legs from the
ankles to the knees; in some cases the analgesia is more, in others
STADIUM DEBILITATIS 291
less extensive. He knows all that is going on around him, but
takes no apparent notice.
Hallucinations of hearing may arise in this condition.
The flow of thought is slow, in contradistinction to the “ flight
of ideas’’ of the acute stage. If undisturbed the patient sits
silently in the same position all day long. There is neither
rigidity, flaccidity nor flexibilitas cerea. If the patient’s arm
be raised by the doctor to some unusual position, he quietly
returns it to the comfortable posture from which it was removed.
He is unemotional and his more lately acquired instincts are in
abeyance. The memory is fairly good.
In a few cases this post-maniacal condition of stupor becomes
exaggerated and persistent, and it assumes the characteristics
of anergic stupor to be presently described. Usually, however,
in the course of a few weeks the stupor gradually passes off
and the patient enters the stage of convalescence. The skin
becomes clear and the flesh firm, the body-weight increases, the
appetite returns and all the organs begin to function normally.
Complete recovery usually takes place within a few months;
but it must not be forgotten that in some patients a state of
melancholia supervenes.
Simple mania is a milder condition, similar to that which occurs
to a slight degree in most normal individuals about the seven-
teenth year, when a boy begins to feel that he is a man and that
the world lies at his feet. He goes to the University feeling con-
fident that he will be able to take all the degrees it offers, and any
remonstrance on the part of his parents is regarded as nonsensical
interference. When this feeling gets out of hand the boy becomes
a simple maniac. He buys a revolver in order to retaliate against
any parental interference, becomes engaged to many girls, drinks
whisky and shaves his hairless face so as to be a man. One
patient sawed off the corner of the drawing-room table because it
was in his way. The simple maniac pays unusual attention to
his dress, which is extravagant; he wears flowers in his button-
hole and uses scent. He is garrulous, boastful, argumentative
and at times brilliant in repartee. His memory is quite accurate.
His emotions are excessive, he is either exuberantly jovial or
extremely irritable. The deeper meaning of many of the above
symptoms will be obvious to the medical psychologist.
Although the above condition happens most characteristically
during the period of adolescence, it may occur at any time of life.
The author has seen one case at the age of fifty-two, and many
during the fifth decade.
292 MIND AND ITS DISORDERS
Acute delirious mania is a phase of intermittent insanity in
which all the characteristics of acute mania are excessive and
there are, furthermore, physical signs of an acute febrile disturb-
ance. The temperature is raised, commonly to 101° F., some-
times to 103° I’.; sordes appears on the lips, teeth and tongue, |
which latter is coated with a thick brown fur; the pulse-rate is
perhaps 140 to 150 and the respiration 30 to 35. Complete in- |
somnia and absolute constipation are the rule. The patient
refuses food and is frequently unable to retain any nourishment
or medicine, even administered by means of the feeding-tube.
Chronic mania presents the same symptoms as acute mania;
but it differs in that the condition does not pass away, the patient
remaining permanently in a state somewhat resembling the
stadium acutum above described. Further, the symptoms are
less marked than in acute mania. In chronic mania we some-
times meet a remarkable exaltation of memory (hypermnesia).
One patient, who was in Bethlem for some years, could always
remember the name of any medical man who had visited the
wards, perhaps years previously, although the institution was
then visited by a large number of medical men every year.
Chronic maniacs are lable to acute exacerbations from time to
time, each of which leaves the patient more weak-minded. The
memory gradually fails. The above patient, indeed, reached a
stage in which he failed to recognize former Bethlem house-
physicians whom he had at one time seen daily for six months.
Prognosis.—The outlook in all cases of acute and simple mania
is, as a rule, favourable for the existing attack. A few cases of
acute mania die of exhaustion from the disease or from some
intercurrent complication, and a still smaller number become
transformed into a condition of chronic mania. The duration of
most cases of acute and simple mania is from five to seven months,
but it may be as short as a fortnight or as long as two years.
If the patient has had a previous attack, the physician will, as
a general rule, do well to be guided in his prognosis by the dura-
tion and character of that attack.
The prognosis of chronic mania is bad in respect of recovery
but good in regard to life. The author has, however, seen a few
cases of chronic mania recover, one after about five years.
It has been said that about 50 per cent. of cases of acute
delirious mania die of exhaustion from the disease and that a
considerable proportion of the remainder become permanently
weak-minded. This is certainly not the experience of the author,
who regards these cases more favourably. A considerable
CHRONIC MANIA 293
number have already entered upon convalescence within a month
if they have been energetically treated. About 25 per cent. die
of exhaustion, and the author is now of opinion that some of
these might possibly be saved. He has seen but one case that
became permanently weak-minded.
Treatment.—Many years ago when I approached the study
of mental disease it was a great surprise and somewhat of a
shock to me to find that wan and emaciated patients in a state
of acute excitement were allowed to spend their days dancing
round the gardens of institutions for the insane, save when
their motor excitement proved too much for the other patients,
when they were allowed to perform their wild gyrations within
the confines of a padded room. On inquiry I was told that it
was better to let them “ have it out ’’, so I subscribed to existing
doctrines and many a time satisfied my desire to do some real
good in the world by disturbing a quiescent maniac and setting
him to take a run round the garden.
Truly it was difficult to discover the rationale of such treat-
ment; but conscience could always be salved by the shibboleth
“Vis medicatrix nature ’’; but now, after years of experience
and repeated observation of the results of Continental methods,
I am constrained to dissent from the traditions of this country
and to advocate as the essential principle of treatment of acute
maniacal states what our forefathers would have stigmatized and
some of the present members of our branch of the medical pro-
fession still stigmatize as a heresy—rest ! rest in bed !
I admit that it is no easy matter to get an acute maniac to rest
in bed; but the difficulty is not insuperable. In many cases a
tactful attendant is all that is required: his duty is to induce the
patient to remain in bed, not to hold him there, for it is no rest
to be held down.
If other measures fail, a course of prolonged baths should be
tried. The use of such baths has been in vogue since the days
of Pinel and many have been the modes of application. The
outcome of experience is that the following is the best:
The temperature of the bath should be 96° to 98° F. On the
first day the patient remains in the bath for half an hour; on
the second day, one hour; third day, two hours; fourth day,
three hours, and so on up to six or seven hours a day. It is
not known how the bath acts, but its effect is that the patient
gradually becomes more and more restful. He enjoys the bath;
he may at first be somewhat restless and turn somersaults in
it. Should this activity become at all excessive, he can soon
294 MIND AND ITS DISORDERS
be dissuaded froin it by a sympathetic attendant, who should
never leave the bath-room. In time the soothing effect of the
warmth or the pressure of water, whatever it may be, begins to
tell and the patient sinks into a state of quietude. After the
bath he should return to bed and be persuaded to remain there |
as much as possible. Females undergoing the treatment should |
wear a gown of some sort or a chemise. A course of iron tonic
should be given at the same time, inasmuch as this bath treat-
ment is rather liable to cause chlorosis.
When it is decided that the course has done its work, the
duration of the bath should be gradually diminished. Bed-
treatment should then be substituted, perhaps with the addition
at first of a daily bath of one hour’s duration.
As soon as quietude is restored the patient may sit up half an
hour twice a day for a smoke; but he should not be allowed to
play exciting or exhausting games. As he improves, this half-
hour may be gradually prolonged and he may be allowed to
perform light duties about the room or ward.
Meanwhile the patient must have abundant nourishment. He
should take in addition to his ordinary food 3 pints of milk, at
times with cream, and he should have a plentiful supply of
biscuits while undergoing the bath treatment. A glass of stout
or port with dinner and supper may serve as an appetizer and as
nourishment; but alcohol must, of course, be withheld if it has
played a role in the causation of the disorder.
If, as in some cases, there should be absolute refusal of nourish-
ment, the patient must be tube-fed. Tube-feeding lasts rarely
more than a few days in the case of a maniacal patient. If
undigested food from the last meal should be returned up the
tube, this should be taken as an indication for subsequent meals
to be peptonized.
The only drugs which are indicated in the treatment of acute
maniacal states uncomplicated by intercurrent disease are motor
sedatives and hypnotics. Sulphonal serves the purpose of both
and may be regarded as almost a specific for acute mania. The
dose, which should be administered every night as long as the
insomnia is severe, is 30 grains for a man, 20 grains for a woman.
Sulphonal rarely acts on the first night, but after about three
doses its effect begins to be noticeable; there is more sleep during
the night and less motor activity during the day. Isopral is a
milder drug of the same nature, which often acts beneficially;
the dose is 30 to 40 grains for these patients. It should be
administered in a spoonful of jam.
TREATMENT OF MANIA 295
Dial and amylene hydrate are satisfactory hypnotics in these
cases, and hydrobromate of hyoscine, 79 grain three times a day
by the mouth, frequently serves as a useful motor sedative.
The action of the bowels should be regulated on ordinary
medicinal principles.
Acute delirious mania is a condition which demands special
consideration because it is liable to resist all the ordinary methods
of treatment. The patient gets no sleep in spite of drachm
doses of sulphonal; he refuses all nourishment and if he is forcibly
fed with even a small quantity of liquid food his stomach rejects
it; he is constipated, no aperient can be administered and it is
impossible for the attendants to give him an enema. What is
to be done ?
Chloroform is our sheet-anchor in this condition. The patient
is anesthetized and the rectum cleared, either digitally or by
means of anenema. His temperature is taken, he is washed with
warm water and soap and changed into comfortable clothing.
While he is deeply under the anesthetic a tube is passed into the
stomach, which is then washed out with a dilute solution of
carbonate of soda, followed by warm water. A feed is then
administered consisting of I pint of milk, 2 ounces of cream,
2 ounces of white mixture and 40 grains of sulphonal. The
patient is made comfortable in bed and the anesthetic continued
carefully for another hour. He is not aroused from the anes-
thetic, but is carefully watched until his sleep is apparently
natural. He is then left in quietude. The sleep continues for
many hours; he wakes up refreshed and makes a fairly rapid
recovery. Although the author’s experience of this method of
treatment is limited to a small number of cases, the beneficial
results have been so striking that he has no hesitation in recom-
mending the method as a routine treatment for obstinate cases
of acute delirious mania. In each of the cases the patient’s life
was undoubtedly saved by the adoption of this method.
Chromic mania calls for no special treatment except during
an acute exacerbation, which should be treated like an ordinary
case of acute mania. In a county asylum much unskilled, or
even skilled, labour can be obtained from these patients.
ANERGIC STUPOR.
Anergic stupor is a phase of intermittent insanity in which the
patient is neither excited nor depressed, but apathetic, lethargic
and torpid. The condition is rare. It may be primary in its
296 MIND AND ITS DISORDERS
origin; more frequently it develops from melancholiac stupor of
from post-maniacal stupor.
Physical Signs.—The patients are, as a rule, in poor physical
health and ill-nourished. Except for an occasional excess of .
secretion of sweat about the face, there appears to be little dis-
turbance of the cutaneous secretions; but the complexion is, as _
a rule, sallow. The temperature is in many cases subnormal.
The pulse is slightly increased in frequency and of low tension;
the respiration normal in frequency but shallow. The ex-
tremities are nearly always cold and, at least in cold weather,
blue, swollen and cedematous. In some cases in which there is
marked cedema of the hands and feet, some cedema may also be
observed in the face, especially about the nose and lips.
There is little evidence of disturbed digestion, but the patients
are invariably constipated. The urine is deficient in quantity,
high-coloured and contains excess of indoxyl. In _ females
amenorrhecea is the rule.
The patients do not suffer from headache, pain or subjective
sensations of any kind and there are no local paralyses. There
is well-marked peripheral analgesia.
There is no rigidity or flexibilitas cerea; the limbs are flaccid.
If the arm be raised and allowed to fall, it “ flops ’’ down to
the patient’s side. Similarly if the leg be raised, it falls to
the ground lke a log. In severe examples flaccidity of the
trunk may sometimes be observed. The patient lies in bed in
any position in which he is placed, for all the world like a rag
doll. There is muscular hypotonia or atonia as shown in Fig. 46:
this patient, if placed in the attitude there represented, would
remain in it for hours together. There is no laxity of the lga-
ments; it is impossible, for example, to hyperextend the fingers,
as in many cases of amentia,
The superficial reflexes are diminished, the plantar reflex being
accompanied by a flexor response of the great toe. The tendon
reflexes are increased. A tap on the patellar tendon elicits a
knee-jerk of large excursion, rapidly followed by a brisk con-
traction of the semimembranosus.
There is almost complete absence of movement, the patient
remaining in any position in which he is placed. Similarly
speech is absent; at most, the patient replies in monosyllables.
The electrical reactions of the muscles are normal.
Mental Symptoms.—In view of the extensive analgesia and,
perhaps, anzesthesia which occur in most of these cases it is not
surprising to find that consciousness is at a low ebb. Of idea-
ANERGIC STUPOR 207
tion there seems to be none; and, in some cases at least, the same
may be said for perception, for Clouston quoted the case of a
female patient who took no notice of another patient committing
_ suicide by hanging herself before her very eyes. We may there-
fore accept the statement of stuporose patients after recovery
-that they do not experience hallucinations or illusions during
the course of their illness.
If there is no perception there can be no emotion, for emotion
is essentially a reaction to a percept; nor can there be any in-
stinct; in the majority of these cases instinctive movement is
absent as well as volitional. The instinct to eat is lost. If a
plate of food be placed before the patient he takes no notice of
Fic. 46.—HYPOTONIA IN ANERGIC STUPOR.
it and, if left to himself, would starve. He has to be fed and
dressed by the attendants. Nevertheless, in mild cases of anergic
stupor the patients will dress themselves, and females may do
their own hair. Some will also take the trouble to visit the
water-closet when necessary, but the majority are wet and dirty.
Again, if there be no perception, there can be no memory.
Accordingly we find that most of these stuporose patients on
Tecovery have no memory of the major part of their illness; it
is blank.
It is difficult to ascertain how much they sleep. hey he
quietly in bed the whole night through and it would be most
unwise to disturb them in any way for the purpose of deter-
mining whether they are asleep, lest this should arouse them
298 MIND AND ITS DISORDERS
from slumber. It is also difficult to decide how much their
stuporose condition serves the purposes of sleep and how much
true sleep they really require.
Delusions do not arise during the course of anergic stupor;
but a few patients subsequently develop delusions as to the
nature of their illness. For example, one patient thought that - |
she must have been hypnotized by some person or persons un-
known. .
Anergic stupor lasts from three months to three years ac-
cording to the severity of the case. Although treatment may
modify the course of the disease, many cases last from two to
three years in spite of the most generous and energetic methods.
When the stupor is about to pass off, the patient’s instincts
return gradually to their normal condition. He begins to eat of
his own accord, becomes clean in his habits and takes some
interest in his personal appearance and surroundings. He moves
about, holds conversation with others and the mental condition
becomes clear. As a rule, there is a slight reaction after the
prolonged period of quiescence and the patient has an attack of
mild excitement lasting a few weeks.
Prognosis.—The prognosis in cases of anergic stupor is good,
and the recovery, as a rule, complete. A few cases terminate
in a short, sharp attack of acute mania or melancholia. It is
regrettable that a small number of patients who are unfortunate
enough to get into the hands of persons, even medical men,
unskilled in the treatment of such cases, die of inanition.
Treatment.—It must be at once understood that it is useless to
attempt to “‘rouse”’ these patients. It would be as reasonable
to treat a case of toxic amblyopia by sending him to view the
pictures in the Academy as to treat a case of anergic stupor by
sending him holiday-making in the country or globe-trotting.
The proper treatment of anergic stupor is rest in bed and a
generous diet. The “ gospel of fatness’ applies to this as to all
forms of insanity. Tube-feeding is rarely required, but it is
almost always necessary for the attendants to administer every
meal for months together by means of a spoon or feeding-cup.
The minimum daily diet should be 4 pints of milk, 4 eggs, and
4 ounces of cream. This may be varied occasionally with bread
soaked in some nourishing soup (not a meat extract), or milk
puddings.
If it can be definitely ascertained that the patient gets in-
sufficient sleep, a couple of drachms of paraldehyde nightly can
do no harm and will probably do much good.
TERMINAL DEMENTIA 299
General massage for an hour daily helps to increase nutrition
and, when the patient has put on a considerable amount of
flesh, an attempt may be made to restore sensibility to the
anesthetic limbs by the daily use of an electrical wire-brush
and cold baths.
When he has acquired a good covering of fat, he may be
allowed to get up regularly at midday. He should not be
allowed to rise earlier until there are definite signs of the illness
drawing to a close.
TERMINAL DEMENTIA.
As already stated, periodic insanity tends but little to dementia.
Intermittent insanity, on the other hand, tends to dementia to
such an extent that it may be taken as a fairly constant rule that
Fic. 47.—ANALGESIA IN A CASE OF TERMINAL DEMENTIA
OF MANIACAL-DEPRESSIVE INSANITY.
the sixth attack leaves the patient so weak-minded that he is
no longer capable of managing himself or his affairs, and for
ever afterwards requires permanent care, usually in an asylum.
Each attack leaves him more weak-minded, the condition sub-
sisting between the earlier attacks being known as “ partial
dementia ”’
In partial dementia the most recently acquired mental func-
tions show signs of degeneration. Some deficiency of reasoning
power is manifest in the patient’s conversation; the formerly
ardent patriot may become, for example, a rank pacifist. Volun-
300 MIND AND ITS DISORDERS
tary attention cannot be sustained so well as formerly; duties
are neglected and the man’s attention is more likely to be domi-
nated by his instincts. In some cases this latter characteristic
may land the patient in gaol, for the legal mind is mostly in-
capable of recognizing partial dementia. There is deficient
control of the emotions and outbursts of anger are common.
The memory shows signs of failure, especially inability to recall
proper names and to remember recent events.
In the terminal stage, after some dozen attacks or more, the
mind is completely lost. There is peripheral anesthesia, more
or less excessive. The man is incapable of recognizing his friends
or of apprehending the nature of his surroundings. He has no
idea of time and his memory becomes a blank. His instincts
and desires are gone; he has no idea of feeding himself and
consequently he has to be spoon-fed. He is periodically wet
and dirty and therefore, unless carefully tended, liable to bed-
sores. His attention cannot be aroused; he can understand
nothing that is said to him and there is no attempt at speech;
lastly, he may be bedridden and incapable of any but reflex
movement.
All physical signs of the acute stages of the disease have, as a
rule, disappeared by the time the patients reach this terminal
condition. Their muddy complexion may give them a generally
unhealthy appearance, but they are not especially liable to con-
tract disease, except perhaps phthisis. Asa rule, therefore, they
live to old age. On the other hand, their power of overcoming
and surviving any intercurrent disease is smal] and their general
vitality is so low that the most trivial malady is likely to lead to
a fatal termination.
PATHOLOGY OF MANIACAL-DEPRESSIVE INSANITY.
Post-mortem examinations and the microscope have failed
alike to throw any light on the nature of these diseases. In some
cases of long standing the weight of the brain is slightly less
than normal and there is some excess of cerebro-spinal fluid.
On microscopical examination it is found that there is slight
chromatolysis of the largest cells of the cortex, but scarcely more
than may be found in the brains of patients dying from some
thoracic or abdominal disease in a general hospital.
Accordingly many theories have been advanced as to the
essential nature of maniacal-depressive insanity, most of which
take little or no cognizance of the brain being the organ at fault.
PATHOLOGY OF MANIACAL-DEPRESSIVE INSANITY 301
Some writers have claimed that indigestion is the cause of the
disease, others fix on constipation; others again blame the
kidneys and Craig attributes the disease to alterations in the
blood-pressure.
In those materialistic days the present writer used to give
reasons for supposing that there is an intraneuronic intoxication,
but all such hypotheses have now been laid to their well-deserved
rest and the tracing of hereditary factors never added one iota
to our real knowledge of the malady.
Although all sorts of physical manifestations have been
described, no physical basis for the disease has ever been demon-
strated in spite of the most careful macroscopical, microscopical
and chemical investigations, and we have to face the fact that the
maniacal-depressive psychosis is a pure psychosis.
The psycho-analysis of several of these patients by Professor
Freud and his disciples has thrown a flood of light on the true
nature of the malady. Although it is frequently possible to
discern some psycho-analytical interpretation of the symptoms
during the course of an attack of mania or melancholia, a thorough
psycho-analysis of the patient can only be undertaken during the
intervals between the attacks.
It would appear that the melancholia is the original or radical
phase of the psychosis, which is erected on a basis of repressed
sado-masochism. During the infantile hfe of the patient there
has been somebody of biological importance (usually some near
relation such as father or mother) whom he ought to have loved
and perhaps did love consciously, although reasons occurred for
an unconscious hatred of this same person. Consequently there
is an unconscious desire to punish this person; but another curious
‘complication then arises in that the patient unconsciously identi-
fies himself with this object of unconscious hatred (introjection),
the result being that the reproaches are directed against his own
ego by his super-ego or ego-ideal. Hence arises the sado-maso-
chistic state of self-punishment with its self-reproaches, delusions
of unworthiness and wickedness and the still less disguised
manifestation—suicide.
Mania, on the other hand, is to be regarded as a sort of sym-
bolized triumph of the patient on the occasion of his acquiring
freedom from the object which has caused his suffering. In some
patients the excitement takes the form, not of triumph, but of
anger. Of course he does not know why he triumphs or why
he is angry; he does not even know who or what is the object
of his triumph or anger.
302 MIND AND ITS DISORDERS
During the course of the psycho-analysis other complexes,
varying from patient to patient, become revealed. Repressed
homosexuality, for example, is by no means uncommon.
REMARKS ON THE GENERAL MANAGEMENT OF INTERMITTENT
AND PERIODIC INSANITIES.
We have seen that the characteristic of these insanities is a
tendency to recurrent attacks of mental disorder, each attack
resembling the last in character and duration, and the problem
arises whether it is possible to avert them without psycho-
analysis. To a certain extent it is. The patient should lead
a regular life, have plenty of sleep and nourishment and avoid
exciting and worrying pursuits. Many of these patients would
never come under observation at all if they had a thousand a
year of their own and expended it properly.
A patient who has once had an attack of the kind described in
this chapter should for ever afterwards be weighed once a month.
If he has lost a pound in weight, he should at once set to work to
put it on again by allowing himself a couple of pints of extra
milk each day. If this is insufficient, he should take extra
rest, preferably by going to bed for a few days. Sleeplessness
can often be averted by taking a glass of hot milk and a few
biscuits on retiring for the night. The author is disposed to
think that a vegetarian diet is more suitable for these patients
than a meat diet; not that the diet should be exclusively vege-
tarian, but that the amount of meat should be limited.
In cases of periodic insanity wherein the patient breaks down
at a given time of year in spite of all precautions, it is often
beneficial to have an entire change of scene and surroundings a
couple of months before the expected attack. If the patient
lives in the country, let him take to a town life, and vice versa;
or let him live in a hydropathic establishment, where the regular
life is especially beneficial to neuropaths.
Unless the patient is prepared to undergo psycho-analysis
during the intervals between his attacks, he must make up his
mind to be somewhat of a valetudinarian, ever watchful for
prodromal symptoms, ever careful of his physical health and ever
mindful of his last attack, even after twenty or thirty years have
gone by. When psycho-analysis is seriously undertaken the
doctor and patient must not be disappointed if the treatment
has to be interrupted occasionally on account of sudden attacks
of mania or melancholia. It must not be expected that these
GENERAL MANAGEMENT 303
will cease until the paralysis is complete. The patient himself
knows perfectly well when he has got to the root of his malady
and destroyed it for ever.
The medical man is frequently consulted as to the advisability
of marriage in these cases, and unfortunately there is a popular
delusion that marriage acts beneficially on neuropaths. It is an
obligation upon the medical man to combat this to his utmost,
not only on account of his duty to the State to prevent, as far
as lies in his power, the procreation of neuropathic children,
but also in consideration of the patient. Only those behind the
scenes can have any idea of the ruin, misery and want entailed
by the marriage of neuropaths. I quote two cases:
1. Husband, a dement in an asylum. Son, a ne’er-do-well
(partial dementia after acute mania). Two daughters, typical
alternative insanity, kept at home or occasionally sent to asylum.
Wife keeps the home together. Daughter earns enough to help
mother in doing this and.to keep father out of a county asylum.
2. Wife, a nagging dement at home, the husband being unable
to afford the means to keep her in a private asylum. Wife’s
brother in an asylum, paid for by husband. Two daughters in
an asylum. Daughter died in an asylum. Son, a ne’er-do-well
(partial dementia). Husband a bankrupt, but, having a sound
nervous system to withstand all this stress, sane.
Nevertheless, there are cases of maniacal-depressive insanity
with little or no hereditary factor. These are due mainly or
entirely to circumstances, influences, situations and incidents
which have occurred in the life-history of the individual. When
such patients have undergone an analysis, there is no objection
whatever to their entering matrimony and procreating children.
In fact, their influence on the life-history of their children would
be exemplary.
CHAP CER SVL
PARANOIA.
WHEN a person is afflicted with some unfortunate trait in his
character of which he is ashamed, he is unwilling to admit the
fact to himself and at the same time remarkably intolerant of
the same failing in other people. He also tends to ascribe it to
others who do not possess it. The untruthful man is chary of
giving credence to others, the scandalmonger supposes himself
to be an object of gossip and the man who marries for money
refuses to believe that love can ever- be the sole reason for
matrimony. This mental mechanism, which plays an important
role in every case of paranoia, is known psychologically as
projection. In psycho-analytic terminology we would say that
a person’s knowledge of his faults, failings and deficiencies tends
to be repressed into his unconscious and to be replaced in con-
sciousness by his recognizing them, rightly or wrongly, in other
people.
Paranoia is a psychosis characterized by systematized delusions
which develop progressively as a result of the patient projecting
certain of his repressed complexes upon other people. In
hysteria the repression is converted through compromise into
physical or mental symptoms; in the obsessional neurosis it is
substituted ; in paranoia it is projected. Not only on single occa-
sions, but throughout the patient’s psychotic life this mechanism
is in constant operation, so that he permanently obtains a dis-
torted view of his relationship with the world in which he lives,
forms erroneous judgments and is ever on the alert for evidence
to justify them—with the result that, from his point of view, he
is apparently justified in the opinions he holds. Incident after
incident is misinterpreted and the misinterpretations are woven
into a coherent web until the whole of his mental life is in-
extricably bound in a systematized network of delusions.
Etiology.—The development of the disorder is so insidious
that in most cases it is difficult to determine the age of incidence,
but paranoia usually asserts itself during the fourth or fifth
decade, It occurs more frequently in men than in women. A
hE §
SYMPTOMS OF PARANOIA 305
history of insanity in the family may be obtained in rather more
than half the cases.
The patients are more often single than married and commonly
lead a solitary life. The reason for this will appear later.
In a few cases the repressing forces of the mind have been
enfeebled by a previous attack of mental disease or bodily illness
which weakens the repressing forces of the mind. The beginning
of the disorder is sometimes referred to a definite incident. For
example, one patient’s deterioration was said to date from an
occasion when certain articles were stolen from the pavilion
of his cricket club; in another case the first symptom was alarm
at or suspicion of a certain unknown woman’s motive in staying
unduly long at Mass in the Madeleine at Paris during the patient’s
visit to the church. Occasionally the disorder is initiated by
a dream which is accepted by the patient as a reality. For
example, an unmarried female patient dreamed some eight years
before she came under observation that she was in bed with a
man; this dream laid the foundation for the delusions that her
brother admitted men into her bedroom at night, that she had
had six children and that, at the time of observation, she was
pregnant with twins.*
Symptomatology.—On account of the slow insidious develop-
ment of paranoia, it is usually four to six years before the
relatives of a patient realize that he is suffering from mental
disorder and the advice of a physician sought. We have
therefore little opportunity of studying the psychosis in its
early stages. The history generally reveals that there has been
insomnia at night and incapacity for steady work during the
day; the patient may further have been regarded by his friends
as eccentric but not insane. |
When he comes under observation the most careful physical
examination reveals nothing abnormal, with the exception
perhaps of a certain unsteadiness of gaze which I have noted
in many cases.
Cutaneous sensation, vision, hearing, smell and taste are all
normal; there is neither anzesthesia nor hyperasthesia.
The patient is well orientated and there is no deterioration of
the perceptive faculty. Hallucinations do not occur. On the
other hand, there appears to be an abnormal keenness of the
perceptive faculty. From the commonplace salutations of his
friends he perceives that he is a greater man than he had
* Probably I would now regard this case as an example of paraphrenia,
but it serves to illustrate my point.
20
306 MIND AND ITS DISORDERS
hitherto supposed; in some chance preoccupation of his wife
he sees evidence of her infidelity; in a colleague’s assistance in
his work he discerns a hint that he is neglecting his duty; in a
flower worn by a lady he espies a sign that she is in love with
him; in books, papers and placards he sees many hidden refer-
ences to himself; a group of poverty-stricken children is, for him,
a call from God that he should become a social reformer; an
attack of breathlessness after running for a train is an indication
that everybody, not only himself, eats too much meat.
This excess of perception is determined by a prevailing emo-
tional tone which varies from patient to patient—ambition,
jealousy, love or suspicion; but apart from this there is no
disorder of emotional reaction.
The essential characteristic of paranoia being disorder of
judgment, the patients have no insight into their mental
condition.
It has been ascertained by Cattell that association-time is
prolonged in paranoiacs. The observation may be taken for
whatsit is worth. I have not seen the original paper, but the
criticism which at once suggests itself is that it is not fair to
compare the time-reactions of the insane with those of practised
observers in the psychological laboratory.
The association of ideas is influenced by the patient’s customary
emotional attitude and the whole of his mental life is dominated
by his particular delusion. Otherwise the train of thought is
normal; the patients are capable of carrying on conversations
and discussions rationally, provided the topics have no reference
to their particular delusions. Paranoiacs can play games of skill
as well as, and often better than, normal individuals.
The memory is good. Incidents are correctly remembered,
although the import or meaning of these incidents may be mis-
interpreted in after-years when the mental disorder has become
established.
The conduct is influenced by the delusions. The patients
may disguise themselves so as not to be recognized by their
supposed persecutors, they appeal to the magistrate for advice
how to escape them or perhaps they travel about from place to
place in order to avoid them. One patient journeyed from
Hastings to Newcastle, stopping at many towns on the way in
search of an unknown lady-love. Mattoids and religious para-
noiacs often take to preaching in the public street, writing to
the papers and distributing pamphlets in which they air their
particular fads. More aggressive natures take up the battle
SYMPTOMS OF PARANOIA 307
with their supposed enemies and retaliate by every means in
their power, even resorting to murder in some cases. Paranoiacs
may be the most dangerous patients with whom we have to deal.
Yet there is a class of so-called “ resigned paranoiacs ’’ who
accept the situation of being detained in an asylum and patiently
wait the time when the doctors and others will realize their
mistake and set them free. It is, however, necessary to bear in
mind that many such patients are suicidal.
The paranoiac may be excessively garrulous; otherwise speech
and articulation are normal. Similarly these patients are apt
to write letters of inordinate length, not uncommonly fifty pages
of foolscap. The letters are coherent and the calligraphy is
unaltered.
On the foundation of an ill-balanced temperament and dis-
ordered perception there is erected a coherent system of delu-
sions the import of which forms the basis of classification of
paranoiacs. Disorder of judgment is the essential feature of
paranoia.
There are two large classes of paranoiacs:
1. The eccentrics or mattoids; and
2. The egocentrics including
(a) Persecuted paranoiacs,
) Exalted paranoiacs,
c) Litigious paranoiacs,
) Religious paranoiacs,
e) Amorous paranoiacs,
f) Jealous paranoiacs and
(g) Hypochondriacal paranoiacs.
Of the two classes the former is probably the larger; but we
see more of the latter in asylums because egocentric delusions are
on the whole more liable to lead a patient into open conflict
with society and to necessitate his sequestration.
The Eccentrics or MATTOIDS are people with wild, altruistic
impersonal theories to which they give vent in voluminous
books or in harangues to crowds in the open spaces of the town
in which they live: but all their activity leads to nothing; they
are regarded simply as faddists or cranks and no further action
is taken. -They are full of absurd projects and utopian ideas;
they preach pacifism, Christian Science, anarchy, revolution,
“back to the land’’, vegetarianism, anti-this, anti-that and
anti-the-other-thing. Some teetotallers who are anxious to
finger other men’s souls belong to this class. Many wear
308 MIND AND ITS DISORDERS
pieces of coloured ribbon or some other badge that all may
know the views they hold. Some are engaged in grotesque
inventions; one patient went so far as to present to the Patent
Office a specification for manufacturing gold from husks of
corn.
The essential characteristic of the mattoid is that his view
of life is distorted in such a way as to lead him to exaggerate
the importance of trivialities, in popular parlance, to “ make |
mountains out of molehills”’.
These are the “‘ borderland ’’ cases of insanity.
EGOCENTRIC PARANOIACS, as the appellation implies, suffer
from delusions in which their own personality evidently plays
the most important réle.
Delusions of persecution are the natural outcome of a sus-
picious temperament. For the suspicious man there lurks in
everyday incidents a hidden meaning of ill omen. People
sitting at their windows are there to watch his movements, a
carious tooth is the result of secret poison, the non-success of
a commercial venture is the work of an enemy, policemen on
the beat at night are keeping a special watch on his doings,
small groups of friends in conversation are discussing his fate
and questions in Parliament secretly refer to his evil influence
on the State. In this way the patient gradually arrives at the
conclusion that a secret society, such as the Freemasons, or a
religious body, such as the Jesuits, is conspiring to do him injury.
In other cases he accuses whole nations of plotting against him;
in yet others the conspiracy is worldwide. On the other hand,
some patients fix upon one particular person as being the cause
of all their troubles, and in turn persecute him. These are indeed
‘most dangerous patients and not infrequently carry their revenge
as far as murder.
Delusions of exaltation are almost certain to appear sooner or
later in conjunction with delusions of persecution. The patient
begins to look around for a reason why so many people should
be interested in his downfall and some chance incident gives
him the clue. People make way for him as he enters the theatre,
showing that they recognize him to be a person of importance;
a chance resemblance to a portrait of some member of the Royal
Family proves that he is of royal descent; a person of the same
-name inherits a fortune, clearly indicating to the patient that he
himself is the rightful heir and that the possessor of the fortune
has assumed his name; the congregation rises and the organ
peals at the moment when he enters the church because he is a
EGOCENTRICS 309
prophet of the Lord, or he is awarded bedroom No. 3 on his
entry into the asylum for the reason, obvious to him, that he is
a member of the Trinity. But delusions of exaltation are not
always a sequel to delusions of persecution; they frequently
arise contemporaneously with or independently of such delusions.
In some cases the patient fixes upon an accident in his remote
past which suggests the possibility that he is a great personage.
One patient, for example, recalled an occasion when a party of
children at play, including himself, was stampeded by a runaway
horse. After forty years the possibility occurred to him that,
on being subsequently claimed by their respective mothers,
these children might have been exchanged and that he might
be the heir to a dukedom. Possibility became probability and
probability became certainty that he was in reality a duke.
Litigious Paranoia.—When a paranoiac imagines himself to
be persecuted by a single individual he himself is liable to turn
persecutor. He calls at the house of his victim at all sorts of
opportune and inopportune times; and when the door is closed
on him, as in due course it invariably is, he lies in wait for his
supposed enemy or follows him about wherever he goes, in order
to air grievances, to threaten him or injure him in some way,
perhaps to murder him. He also writes threatening letters and,
if he is a man of sufficient means, brings the case into court and
claims damages. He loses but resolves to carry on the case and
takes it from one court to another, squandering his money in
litigation. These patients do not hesitate to forge incriminating
documents and to bring them forward as evidence; they may
even bear false witness in court to attain their ends, for it is
characteristic of them to disguise the truth.
They fill reams of paper in setting forth their complaints to
persons in authority, and in speech they are voluble or even
eloquent. Pride and self-esteem dominate their character;
they believe themselves to be incapable of doing wrong. As a
result they become hypercritical of the doings of others and,
when they find themselves sequestrated in an asylum, they are
a plague to the institution. They criticize the routine, get up
trumpery charges against the attendants and write complaints
against the medical officers to the Board of Control.
Religious Paranoia.—These patients devote their attention
to the religious side of life. They feel that they have a call
from God to lead sinners to salvation. They become prophets,
mystics or spiritualists and believe that they are in communica-
tion with the unseen world.
310 MIND AND ITS DISORDERS
Amorous Paranoia.—In this condition we have to deal with
a class of patient who falls in love with some member of the
opposite sex and believes his or her love to be reciprocated,
although the object of admiration has never wittingly given any
justification for such a supposition. A casual glance, a change
of dress or a flower in the buttonhole is taken to mean that
the patient’s attentions are favourably received. He addresses
poems and love-letters to his supposed sweetheart; and when
they are returned and he is told in writing that he can entertain
no hope of requital he considers that this is done to try the
strength of his affection. Accordingly he becomes more im-
portunate, determined and even threatening. Ultimately his
attentions are so aggressive as to necessitate his removal to an
asylum.
Somewhat similar to the above are those patients who disown
their parents and claim to be admitted into the circle of another
family. There is also the patient who fixes upon an unfortunate
individual and becomes the torment of his life by wishing to be
claimed as his son.
Jealous Paranoia.—The psychosis frequently manifests itself
in the guise of unfounded or excessive jealousy. The husband 1s
insanely jealous of his wife and suspects her of infidelity, the most
ordinary happenings proving sufficient ground for suspicion:
the sofa cushions being arranged not quite as usual or men hurry-
ing past the window ostensibly to catch their morning train,
but really to avoid observation by the patient ; or the wife suspects
her husband because he is late for dinner or has joined a choral
society or takes her to the theatre (not to see the play but te look
at some other woman). The patient accompanies him, not to
see the play, but to watch her husband’s gaze. It need not be
pointed out that such marriages are very unhappy; but let the
picture be a warning never to advise marriage to any person in
whom you have reason to suspect a homosexual trend, conscious
or unconscious.
Hypochondriacal Paranoia (Hypochondriasis).—There is a small
number of egocentric paranoiacs who project their complexes,
not as the behaviour of others, but as that of their own organism.
From their youth up they worry unnecessarily about the condi-
tion of their health, exaggerate trivial abnormal sensations into
important symptoms of some terrible organic disease, read
patent medicine advertisements and other such publications,
discover in themselves all the symptoms therein suggested and
accordingly buy and take any number of quack nostrums. The
VARIETIES OF PARANOIA 311
condition is progressive and the patients may finally reach a
state in which they believe day after day, year in and year out,
that their last hour has come in spite of their perfectly healthy
aspect and reassurances from their friends. They constantly
want the doctor to examine them in the hope that he may be
able to discover some other cause of their wretched condition
than disease of the imagination. In reality they are in good
physical health and inordinately fat; for their appetite, of which
they take full advantage in order if possible to keep themselves
alive, is enormous.
Some of these patients rail at the doctors for not paying
more attention to their case, for not discovering the cause of
their illness or for giving them the wrong medicine. Some even
ascribe their condition to a particular bottle of medicine which
he gave years ago. Then they become querulant paranoiacs,
persecute their doctor, threaten him, sue him for damages in a
court of law or even make attempts on his life. Hypochondriacs
sometimes attempt suicide, not to end their misery, but to draw
attention to their case. They do not as a rule intend that the
attempt should be successful, but occasionally it is. Under
such circumstances the jury returns a verdict of suicide whereas
the truth of the matter is that death was accidental.
Diagnosis.—Paranoia is recognized by the slow, insidious
nature of its beginnings and the chronic progressive systematiza-
tion of the delusions on which the patient bases the whole of
his mental life. It is to be distinguished from the somewhat
similar delusional states occasionally arising as a sequel to
attacks of intermittent insanity by the definite history of an
attack of mania or melancholia in the latter. Should the patient
have been seen before the physical signs of mania or melancholia
have disappeared, there can scarcely be any difficulty in the
diagnosis.
Dementia paranoides is distinguished by a more rapid onset,
the presence of mannerisms, negativism and other signs of
dementia preecox and also by persistent hallucinations and
their important réle in determining the character of the
delusions.
Paraphrenia is differentiated by the coexistence of hallucina-
tions. They are usually present before the patient comes under
observation. If not, the diagnosis may be difficult.
General paralysis, which may occasionally present symptoms
suggestive of paranoia, may be recognized by the characteristic
physical signs of that disease.
312 MIND AND ITS DISORDERS
Prognosis.—Paranoia is a hopelessly progressive condition with
no tendency to dementia. There is but little hope of recovery.
Pathological Anatomy.—There is no true morbid anatomy of
the psychosis, but it has been said that congenital modification
in the arrangement of the cerebral convolutions 1s sometimes
to be found and, according to Morselli, an increase of the con-
stituent elements of the association. areas.
Some of the patients exhibit physical stigmata of degeneration,
especially physical characteristics of the opposite sex.
Psychopathology.—Freud was the first (about 20 years ago)
to discover and elucidate the fact that a certain case of paranoia
(that of Dr. Schreber, who published his own autobiography)
was erected upon a basis of repressed homosexuality and since
that time it has gradually become established that this is the —
invariable foundation of the disorder. Homosexuality is
naturally repugnant to everybody and particularly to most
people who have homosexual tendencies themselves. They
refuse to believe that they are especially attracted to members
of their own sex and repress the idea into the unconscious; but
should the repression fail, the complex tends to assert itself in
delusional disguise—as paranoia. The psychical mechanism by
which this transition takes place is as follows:
The paranoiac always starts with the unconscious premise
‘“T love the man ’’ (for convenience I am assuming the patient
to be a male).
Persecuted Paranoia.—‘‘I love the man’’—an_ intolerable
idea, therefore becoming repressed and replaced in consciousness
by “Ido not love him; I hate him”. This by projection becomes
‘““ He hates me ’’, “‘ I am persecuted by him’”’.
Exalted Paranota.—“ I love him ’’—again an intolerable idea,
therefore “ I do not love him, I love myself ’’. This by projection
becomes “‘ Everybody loves me”’, “‘ I am a great person ”’.
Religious Paranoia.—“ I love him ”’ being intolerable, becomes
“ T love Him ”’ (spelt with a capital H), meaning “‘ I love God ”’.
This by projection becomes “‘ God loves me ’’, “‘ I am the chosen
one of God ”’.
Amorous Paranoia.—tThe intolerable ‘“‘I love him’’ becomes
‘““T do not love him, I love her’’. This by projection becomes
““ She loves me ”’.
Jealous Paranova.—“ I love him’”’, as usual, is replaced by “ I
do not love him; she loves him ’’.
Hvpochondriacal Paranoia is somewhat like exalted paranoia,
‘“ T love myself ’’ becoming “ I must take care of myself ”’.
TREATMENT OF PARANOIA 313
Querulant Paranoia is only a special variety of persecuted
paranoia.
Treatment.—Medicines are of course useless and most para-
noiacs have to be sequestrated in a mental hospital, not so
much for their own sake as for the convenience or even safety
of the general public. Some, however, welcome the asylum as
a safe harbour of refuge from their supposed persecutors.
Although psycho-analysis has succeeded in elucidating the
psychology of this disease, it all but fails as a method of treatment.
The patients very rarely have insight and are therefore unwilling
to co-operate with the physician who seeks to cure them of what
they believe to be a non-existent malady. It is not uncommon,
however, in psychological practice to come across a neuras-
thenic with paranoid tendencies and presumably a potential
paranoiac who becomes perfectly normal after a course of psycho-
analysis. During the last few years indeed some psycho-analysts
have had a certain measure of success with some very early
paranoiacs.
But we have not shot our bolt on this problem; there are other
methods of tackling it. For example, the physician who is to
attempt to effect a recovery should be forearmed before he has
his first interview with the patient. He must accept the patient’s
point of view from the first and encourage him to give a detailed
history of his case. The doctor must remain ostensibly unbiased.
While refuting absolutely nothing that the patient tells him,
it is not required that he should openly accept the delusions as
facts. This first stage consists of leading the patient to the
conviction that he has a sympathetic listener. In due course
an occasion arises (after many hours of conversation) when the
medical man has an opportunity of suggesting, in respect of some
quite minor detail, that his patient may have been mistaken.
Although it is essential that the doctor should understand the
psychology of paranoia, he makes no attempt to get the patient
to penetrate his own unconscious mind. He is merely on the
alert for minor misinterpretations and tries to correct them.
As time goes on, an opportunity occurs for suggesting that the
patient may have been mistaken in a matter of rather more
importance and ultimately it may be found possible to deal
with the main delusions. Appropriate fragments of psychology
are occasionally introduced; but the whole procedure requires
an extraordinary amount of tact, for a single false move is fatal
to the patient’s confidence and therefore to success.
Another method is, after similarly gaining the patient’s con-
opel MIND AND ITS DISORDERS
fidence, to develop an attitude of resignation in his mind so
that, although he retains his delusions, he pays no ostensible
attention to them, is prepared to let bygones be bygones,
allows people to think that they are non-existent or, at any
rate, that he does not act upon them and goes about his work
like a normal person. This procedure also requires very careful
and tactful handling. Quite a number of these patients can
ultimately pass muster in the outside world with a little financial
assistance.
COMMUNICATED INSANITY.
FoLiE A DEvUxX.
This is a state of affairs in which two, or sometimes more,
people intimately associated with one another mutually develop
what appears to be identically the same mental disorder, usually
delusions of persecution. The subsequent history of these
patients usually discloses the fact that one of them is a paranoiac
and has induced the other to believe in his delusions; in other
words, he has communicated his insanity to the other. In order
that this should happen it is essential that the two patients
should have been intimately associated, should have many
interests in common, view life from similar standpoints and
have isolated themselves from the outside world. Accordingly
we find that folie a deux usually occurs in two members of the
same family, sisters, brothers, father and son, mother and
daughter or perhaps husband and wife.
It must be understood that the occurrence of insanity in two
members of the same family as a mere coincidence at the same
time does not necessarily constitute a case of folie ad deux. It is
essential that the mental disorder of one patient shall be directly
due to the persuasive influence of the other. For example,
when a woman becomes maniacal on account of the mental
anxiety caused by nursing a maniacal sister, that is not a case
of communicated insanity, because it is not induced by the other
patient’s persuasive influence.
It is said that the delusions are as a rule not so strong in
one patient (the passive element of the couple) as they are in the
other (active element). With this statement I cannot agree; for
it is quite impossible, when such a couple comes under observation,
to discern any mental differences between them and therefore to
determine which is the active element and which the passive.
The following is a good example of communicated insanity:
COMMUNICATED INSANITY 315
Two unmarried sisters, aged respectively twenty-six and
thirty, lived together in a small house in a London suburb.
Gradually they came to neglect their social duties, failed to call
on their friends and, as a natural result, did not receive visits
themselves. Then they felt neglected, thought that their friends
wished to have nothing to do with them, that some scandal
concerning them was rife, that they were being persecuted and
that they should come to some harm. At this stage they drew
up the following document. It was written by the passive
element:
“ September 25, 1905.
“I, A. B. C., and I, D. E. C., do swear that the statement
written below is the truth, the whole truth and nothing but the
truth. If anything happens to us by violence, it will be by the
instigation of the Rev. F’. G. H., through his agents and the
Secret Society to which he belongs. We have been hunted down
since the year the Queen died by the aforesaid agents systematic-
ally day after day, week after week, taking our name away and
shutting all doors on us. The reason of this is that his methods
and their methods are criminal, and they have used them on us
uselessly until to-day, when I called at Vicarage and now
the verdict has gone forth to two next-door neighbours: the
I, J.’s and their servant K. L., who are in their pay, given to
them by old M., who, I conjecture, is one of their chief agents,
and who I only imagine is largely responsible for the N. suicide—
their aim is money and power; they have marked all the rich
families in England with ‘XX’ to my knowledge, to marry
crooked-mined [? minded] women to straight men running to
kill them, then the money falls into their hands. I have been
told to emigrate for a year to South Africa and then return,
but there would be no return.
““M.’s son set off a raid against us last Tuesday to Q——
[a neighbouring suburb].
“The murder in to-day’s paper was no suicide on the Brighton
lime?
Matters were brought to a climax when on a certain day
these patients expected their house to be attacked. At I a.m.
they heard a noise, threw up their windows and shouted for the
police. The police arrived and tried to force an entrance, but
the two sisters kept them at bay for two days with a couple of
ancestral cavalry swords. The police were ultimately successful
and the patients were placed under care.
316 MIND AND ITS DISORDERS
They were put into separate wards, but for many months
were so reticent about the whole affair that it was impossible
to say which was the worse of the two. The younger sister
recovered in ten months, the elder is still under care.
The prognosis is good for the passive element; but the active
element, being usually a paranoiac, does not recover. It is
impossible during the early stages to determine which patient
is the active element, which the passive and pric beset which
patient is going to recover.
Treatment consists of separating the two persons and attending
to their general health. The separation must be continued after
recovery because the passive element is for long afterwards
under the dominion of the active, without either of them being
consciously aware of the fact.
CHA li heise
DEMENTIA PRECOX.
DEMENTIA PRACOX is provisionally regarded as a psychosis, which
makes its appearance in specially predisposed persons usually
between fifteen and thirty years of age and rapidly leads in the
great majority of cases to a profound and distinctive type of
dementia. It comprises a very large number of cases, about
one-eighth of the admissions to asylums, and it is characterized
by a large number of symptoms, many of which may be regarded
as being almost pathognomonic of dementia precox. Its recog-
nition is mainly due to Professor Kraepelin of Munich.
Etiology.—The history of patients suffering from this disorder
usually discloses the fact that they come of an insane stock,
generally on the maternal side, and frequently that theirs is not
the first case of dementia preecox in the family. It has been said,
apparently with some truth, that the children of general paralytics
are specially predisposed to dementia precox. Nor have signs
of mental instability been wanting in the patient: as a rule, he
has not done particularly well at school, he has been seclusive
and impulsive, unduly devoted to religious exercises, emotional
and easily susceptible to the influence of alcohol. Some patients,
on the other hand, display considerable mental ability in early
life.
Physical stigmata are common, such as deformities of the
pinne, palate, hair and hands. The author has observed a
deformity in the patient’s hands, assimilating them to those of the
apes, especially of the chimpanzee, and to those of the lemurs.
The hands are in many instances long, thin and delicate, with
flattening of the thenar and hypothenar eminences; the thumb
looks more or less forward like the other digits, being rotated
outwards instead of looking across the palm. If the terminal
phalanx of the thumb be flexed, it may be observed that it fails
to undergo the normal amount of internal rotation on the proximal
phalanx. This peculiarity also is to be seen in the apes. Another
common feature is abnormal laxity of the ligaments of the
metacarpo-phalangeal joints so that the fingers can be passively
hyperextended, almost to a right angle.
317
318 MIND AND ITS DISORDERS
These characteristics, taken in conjunction with the facts that
they are sometimes encountered in cases of idiocy, especially
those of the Mongol type, that imbeciles are liable to develop at
puberty symptoms resembling those of dementia precox and
that the above peculiarities of the hands are also to be observed
in the chimpanzee all point to the conclusion that dementia
precox may be regarded as a failure in evolution, as an atavism
or reversion to an ancestral type.
Such a view is corroborated by the statements of the parents
of many of these patients. Some go so far as to say that there
%
35
350
25
20
10 15 20 25 30 35 40 45 50 55 60
4, 3-5|27 [217 |255]228|:50|5-0|3-3]1-2 |r jo-z
Fic. 48.—AGE-INCIDENCE OF DEMENTIA PRA&COX
(AFTER KRAEPELIN).
is nothing the matter with the patient, others say that he was
always in a somewhat similar condition; and one exceptionally
observant and intelligent mother volunteered the remark that
no new symptoms had ever developed in her daughter, she had
but “ gradually become more and more herself ’’.
Nevertheless we are bound to admit that atavism does not
entirely account for all the features of this disease. The rapidity
of the deterioration, the physical ill-health and the possibility
of recovery, though rare, all seem to indicate that some active
DEMENTIA PR#COX 319
morbid process is at work. Further, Alzheimer and others have
demonstrated that, in certain cases of dementia praecox (kata-
toniacs), there are isolated areas of gliosis in the deeper layers
of the cortex. In view of the fact that incidence of most of
these cases is at the age when the sexual functions are most
active, it has been suggested that this disease is due to defective
internal secretions of the ovaries and testes. Other evidence
relating to this matter is given in the section on morbid anatomy
and pathology on page 341. On the other hand, there may
be some purely psychological explanation.
Pighini, in his studies of the metabolic processes in dementia
precox, found that there is increased elimination of nitrogen
and phosphorus during acute stages and diminished elimination
Fic. 49.—SIMIAN HANDS OF DEMENTIA PRAECOX.
of these elements in advanced stages of the disease. From
these discoveries he concluded that there is destruction (or loss)
of nucleo-proteids in the acute phases. These observations
point in rather the same direction.
It is also stated that the cerebral cortex from cases of dementia
preecox is characterized by deficiency of organic and excess of
inorganic sulphur. Berger discovered that the blood-serum of
katatoniacs injected into the posterior lobes of the brains of dogs
caused muscular spasms, apathy and a tendency to constrained
attitudes. This also argues in favour of the auto-intoxication
theory.
Jung claims an exclusively psychical origin of the disorder.
By his special method of psycho-analysis he has been able to
320 MIND AND ITS DISORDERS
reveal repressed complexes and conflicts, almost invariably of
a sexual character. He admits the evidence in favour of the
auto-intoxication theory; but points out that the toxins may
quite well be produced as a result of mental conflicts. Con-
sideration of the anxiety neurosis and exophthalmic goitre
lend support to such a view and I have had patients whose
physical appearance was altered by psycho-analysis (develop-
ment of the breasts and blanching of the hair for example).
Apart from the difficulty of psycho-analysis in dementia
preecox, this process is of little or no therapeutic value for
this disease.
Physical Signs.—At the onset of dementia praecox the patients
are found to be in poor health and ill-nourished. The pulse is
frequent, sometimes irregular and usually of low tension; in
depressed cases the arterial tension is raised. Dr. John Turner
of Brentwood Asylum found the blood-pressure raised in 30 per
cent., lowered in 30 per cent., and normal in 40 per cent. The
skin is often greasy and the complexion sallow. The appetite is
poor, the bowels constipated and menstruation is usually in
abeyance. In katatoniac stupor the extremities are often cold,
the hands are cyanosed and there may be cedema of the hands,
feet and face, especially about the nose and lips.
Dide and Chénais examined the blood of 18 patients. They
found the number of polymorphonuclear leucocytes to be dimin-
ished in 5, increased in 4, and normal in g. Dr. John Turner
found hypoleucocytosis in 5 out of 6 cases. Dr. Lewis Bruce, on
the other hand, found hyperleucocytosis in all cases of hebe-
phrenia and katatonia; but the polymorphs dropped to 50 per
cent. or less “1” a few incurable cases’ (sic).
Occipital headache is a common complaint, especially of those
patients who suffer from amenorrhcea. The hair is often erect
and frequently there is transverse wrinkling of the forehead which
differs from that of melancholia in that it is not limited to the
centre of the forehead but carried out beyond the supra-orbital
ridges, thus causing an expression of surprise or wonder; the
wrinkles are also higher on the forehead than in melancholia.
The pupils are usually dilated but react well to light. Tremor
of the closed eyelids occurs in many cases. The tendon reflexes
may be greatly exaggerated, more than in any other form of
insanity. A tap on the patellar tendon causes a knee-jerk of
wide excursion, followed by a very brisk return due to contraction
of the semimembranosus and, in some katatoniacs, by rectus
clonus. The superficial reflexes are normal.
PHYSICAL SIGNS OF DEMENTIA PRECOX 321
The rigidity which occurs in some cases of katatonia differs
from that of melancholia in its distribution. In melancholia the
rigidity affects the large proximal joints most; in katatonia the
rigidity is uniformly distributed.
All these physical signs are limited to the acute stage of the
Fic. 50.—ERECTION OF THE HAIR IN DEMENTIA PRAECOX.
disease. As a rule they disappear as the patient puts on flesh
and becomes restored to good general health.
If a simple finger movement (flexion and extension) be recorded
on a revolving drum, the tracing usually shows a flattened top
indicating a pause between flexion and extension—as if the muscle
were poisoned with veratrin. Figures 51 and 52, kindly made for
me by Dr. Hewart at Bethlem Royal Hospital, show the difference
FIG. 51.—NORMAL MUSCLE CuRVE.
between a normal muscle curve and one obtained from a patient
suffering from dementia paranoides.
Mental Symptoms.—Patients suffering from katatoniac stupor
may have peripheral anesthesia. In many cases the hands only
are anesthetic; in others the loss of sensation involves the whole
21
322 MIND AND ITS DISORDERS
of the limbs and trunk, with the exception of a small area in
the neighbourhood of the groins. Kraepelin believes the lack
of response of these patients to a pinprick to be a negativistic
sign, the patient simply taking no notice of the prick. The
Fic. 52.—DEMENTIA PRACOX CURVE,
present author contends that there is true anesthesia, if only for
the reason that the loss of sensation has a definite distribution.
Perception and orientation are good. Hallucinations, especi-
ally of hearing, occur in the acute stage of the disease, but they
FIG. 53.—WRINKLING OF THE FOREHEAD AND ERECTION
OF THE HAIR IN DEMENTIA PRACOX,
This type of wrinkling is of bad prognostic significance and, in another
class of case occurring in later life, may be especially helpful in
determining whether a given presenile case is one of anxietas presenilis
or a more curable form of melancholia.
may disappear as dementia supervenes. In the majority of
cases the hallucinations are, as in most insanities, as vivid as
real percepts; but it is especially in dementia precox that faint
MENTAL SYMPTOMS OF DEMENTIA PR#COX 323
mental images are experienced which lack the vividness of true
hallucination and have accordingly been named, not very happily,
pseudo-hallucinations or psychical hallucinations. The patients
realize that these faint mental images differ from ordinary
thoughts in that they are not referred to the environment, not
eccentrically projected.
Cognition and recognition of familiar faces and common objects
are quite good, but most of the patients are unable to form a good
concept of unusual objects. For example, on the production of a
Galton’s whistle for purposes of testing a case of dementia przecox,
the patient remarked: ‘‘ What a pretty thing! Did you pick it
up in the grass?’’ At the time we were in a part of a ward
whence no grass could be seen, and on the instrument there was
no sign of rust to suggest that it might have been lying in a
damp place.
Similarly memory is unimpaired, at least for recent events;
but it has appeared to the author that the memory for remote
events is sometimes confused, because there is occasional incon-
gruity in the patients’ statements about events long past. For
example, one woman stated that she had been married thirteen
years, that her marriage took place in 1895, that her eldest child
was born a year after marriage and that he was now eleven years
old, the year at that time being 1905.
With such slight impairment of recent memory, cognition and
recognition, it might be supposed that there is little disturbance
of the association of ideas, but this is far from being the case.
The majority of these patients display striking poverty of
thought; they sit still in the midst of the most fantastic environ-
ment and apparently think of nothing.
This apathy to their surroundings is but a part of a general loss
of emotional reaction. The patients settle down to asylum life
without evincing the slightest care or resentment at having been
cut off from the outside world; they have no anxiety or fear
for the future, no satisfaction or regrets for the past; joy and
sorrow, love and anger they know not and attention is at its
lowest ebb. That this apathy is real, and merely apparent by
reason of suppression of all outward manifestation of affect, is
clearly demonstrated by the weakness of the “‘ psychogalvanic
reflex "’ in dementia precox; it is even completely absent in
many cases of katatoniac stupor.
It is true that some patients vociferously demand, at every
visit of the doctors, to be set at liberty; but the request is rather
an act of negativism or stereotypy, often initiated by hearing
324 MIND AND ITS DISORDERS
another patient ask for release, than the expression of an emo-
tional desire to go home. One such patient, a lady in Bethlem,
used to demand daily’ to be let out to a workhouse or convent,
anywhere, be the surroundings never so objectionable, but always
with a smile on her face. Another lady used to make frequent
inquiries as to the whereabouts of her mother, but they were
lacking in emotion and gave an onlooker the impression that they
were put merely for the purpose of saying something.
Similar remarks are applicable to the imstincts of patients
suffering from dementia precox. They are seclusive, have no
desire for outdoor pursuits, are not often erotic, rarely make
collections of objects and, when such a collection is made, it is
an example of stereotypy; one such patient, for instance, would
stitch useless articles to a piece of flannel.
When they become destructive their destructiveness is an act
of negativism rather than blind instinct. They tear their clothing
or injure fellow-patients merely because they know that they
should not do so. At the same time we have to realize that
negativism itself is instinct gone astray.
The most striking feature of dementia pracox is disorder of
conduct.
The disorders of conduct characteristic of and almost peculiar
to this disease fall under two heads:
(a) Catalepsy, a state in which there is blind unconditioned
obedience to suggestion from without ; and—
(b) Catatonia,* a state in which acts are performed, not as
a final sequel to a play of motives but as a response to some
unrecognized purely organic stimuli to which a corresponding
psychical state is normally wanting; in other words, catatonia
is a state in which there is blind unconditioned obedience to
abnormal stimuli from within.
Catalepsy includes such symptoms as flexibilitas cerea, auto-
matic obedience or imitativeness (echopraxia and echolalia) and
negativism.
Flexibtlitas cerea (waxy flexibility) is a condition in which
the limbs can be easily moulded into unusual positions and
remain in those positions for some considerable time, perhaps
half an hour or more. In some cases the limb will remain in a
given position for only ten or fifteen seconds; there is then said
to be a tendency to flexibilitas cerea.
Echopraxia is a disorder of volition in which the patient
* Catatonia, the symptom, is distinguished from katatonia, the disease,
by a difference in spelling.
NEGATIVISM 325
imitates any action performed in front of him. If the doctor
stands on one leg, the patient does so too; if the doctor waves
his arm in the air, so does the patient. Such an one may also
imitate the antics of any other patient near him.
Echolalia is the same symptom in the domain of speech.
Whatever is said to the patient he at once repeats; if he is asked
a question he simply repeats it, with or without a change of
te *
4
Fic. 54.—DEMENTIA PR&COX: FLEXIBILITAS CEREA.
pronoun, without giving any answer. If the doctor asks, ‘‘ How
are you to-day ?”’ the patient replies “‘ How am I to-day ?”’
Cataleptic Negativism is a state in which any suggestion given
to the patient immediately arouses the counter-suggestion. If
he be asked to protrude his tongue he closes his lips firmly; if the
dinner-bell rings he walks away from the dining-room; when
dinner is over it may take four attendants to remove him from
the room, so active is his resistance; is it time to go into the
garden it requires four attendants to get him there; is it time to
326 MIND AND ITS DISORDERS
come in again it needs four attendants to return him to his ward.
At bedtime he has to be undressed by force and in the morning
he has to be dressed again by force; if an attempt be made to get
him to talk he remains silent; if told to remain silent he may
respond by shouting down any conversation in the vicinity.
Such patients occasionally strip, tear their clothes, break windows
and furniture or strike other patients, simply because they are
not wanted to do so. One such patient, on being given a new
suit of clothes, was told inadvertently by the attendant not to
tear them up: he tore them up immediately. Subsequently he
improved and told me he would not have thought of tearing his
clothes but for the attendant’s suggestion.
Negativism may sometimes be beautifully demonstrated in
cases of catatonia major by placing one’s hand near that of the
patient as if to touch it; his hand moves away. If now the
observer’s hand be transferred to the other side of the patient’s,
the latter moves back again in the opposite direction like a needle
repelled by a magnet. In this way the hand may be made to
swing to and fro, always moving away from the hand of the
doctor. Similarly if the doctor pretends that he is endeavouring
to avoid the patient’s hand touching his own, the patient’s hand
follows his, the former being constantly attracted as if by a
magnet.
This symptom is not to be mistaken for obstinacy or resistive-
ness, such as occurs in resistive melancholia. That negativistic
behaviour is accompanied by no disinclination or aversion may
be learned from patients who have recovered from the condition.
There are two varieties of eatatonia, major and minor.
Catatonia major is a condition in which the patient stands
rigidly in the same position from morning till night, provided he
is undisturbed. He behavesas a statue, but he is not statuesque.
Being unemotional, he does not strike attitudes like a maniac.
He stands like a dummy, mucus flowing from his nostrils and
saliva drooling from the corners of his mouth.
Catatonia minor includes negativism, stereotypy, verbigeration
and the so-called mannerisms of dementia przcox.
Cataleptic Negativism is a state in which suggestions arise
counter to the patients’ own wishes. They will retain their urine
and faces, although it causes them pain to do so. They try to
speak, but they cannot get their words out; all day long a patient
may repeat “‘ J—I—I-—I ” trying to say something more,
but the something more never comes. This is one form of
verbigeration.
MANNERISMS OF DEMENTIA PRECOX 327
The mannerisms, tricks or antics of dementia przecox, appar-
ently meaningless, must of course have a symbolic meaning of
some sort; but this is difficult and usually impossible to discern.
Without motive the patient walks up and down the same patch
of ground, perhaps holding one arm stiffly and swinging the other.
If anyone happens to be temporarily engaged on a portion of his
parade-ground, he marks time until the person has moved out of
his way; if he is caught in an unguarded moment in a secluded
spot, he is found attempting to stand on his head; if he isasked
Fic. 55.—IKATATONIAC ANTIC.,
The patient was accustomed to stand in this attitude and
to wave one hand,
to rise from a sitting posture, he does so with stiff legs, without
bending his knees; or he may fall on all fours from the sitting
posture. As he paces the ward he turns aside to touch objects
(one form of “‘ folie de toucher’’); he may stand persistently
on one leg or hyperextend his trunk till he is able to see the
ground a few feet behind him. If asked why he has done any
of these things, he admits that he does not know; at most
he will say that it is the Lord’s will that such things should
happen.
328 MIND AND ITS DISORDERS
An incident in my own experience throws some light on the ~
nature of these movements. While talking to a female patient
suffering from dementia preecox (paranoid form) she shrugged
one shoulder. I asked her why she had done so and she replied
that she did not know. “It must have been the underground
electricity.”” A moment later, unconsciously I crossed one leg
over the other; she asked me why I had done this. I had no
reply, I did not know; and the patient informed me that my
action, like hers, was due to the underground electricity. From
this we may learn that these mannerisms are unconscious in-
stinctive acts.
Watch a chimpanzee at the Zoo. He turns a somersault,
climbs to the top of his cage, swings diagonally across it to a
stump of a tree, slides down the stump and arrives at the spot
whence he started. Why does he do this? Partly on account
of the blind instinct of locomotion. But why did he take this
particular course ? The chimpanzee himself could not tell, even
if he had the faculty of speech. So it is with the mannerisms of
dementia precox. They are perhaps monkey tricks, bearing
evidence of the atavistic nature of the disease.
Storch of Tiibingen has made interesting comparisons between
primitive archaic forms of inner experiences and thought with
those in dementia preecox. A translation of his work is published
in the Nervous and Mental Disease Monograph Series (No. 36).
Mannerisms may also be noted in the speech and writing of
these patients. They articulate with unwonted precision, use
stilted modes of expression and converse as if they were making
a speech. If one bids them ‘‘ Good-morning ”’ at five minutes
past twelve they reply “ Good-afternoon’’, and they correct
others in trivial errors of speech. Stilted modes of expression
are also used in their letters, which are frequently addressed to
great personages, often with the most absurd request. One
patient (an Englishman) used to write to the German Emperor,
requesting him to bring the German army over to England to
fetch him out of Bethlem Hospital (this was before the War);
another (a Protestant) would write to the Pope, offering himself
as a mainstay of the Roman Catholic Church. It sometimes
gives us food for thought when we encounter some of these
symptoms in apparently normal people.
One of the most frequently observed mannerisms is the
characteristic handshake. The hand is held out stiffly and
straight, and frequently the handshake is scarcely over when the
hand is rudely withdrawn as if to avoid any expression of cor-
HANDSHAKE IN DEMENTIA PRACOX 329
_diality. With hebephreniacs these features may vary from day
to day, the handshake being most characteristic when the patient
is at his worst.
The calligraphy also is altered; half the words of a letter are
underlined; in some letters curious illustrations are profuse and
Fic. 560.—HANDSHAKE,
Left—normal. Right—dementia precox.
the writing is grotesque in some way or other; for example,
it is penned inversely so that it can best be read by the aid of a
mirror, or the several letters of each word are superimposed
on one another (a form of pseudographia) or they are ex-
I'iGc. 57.—HANDSHAKE OF DEMENTIA PRAECOX.
travagantly long so that they are best read by turning the page
edgewise.
Pseudolalia, another symptom of dementia przecox, is de-
scribed on p. 159.
Stereotypy is the name given to the repetitive movements of
certain of these patients. They perhaps walk continuously over
‘
340 MIND AND ITS DISORDERS
the same patch of grass, round and round in a circle or figure of
eight, swing the arms to and fro above their heads for several
minutes at a time or, like mechanical toy-soldiers, flex alternately
their right and left arms at the elbow.
Verbigeration is the same symptom occurring in the domain of
speech. Phrases, sentences or short rhymes are continuously
repeated for hours together. The following are some examples
which have occurred in the author’s experience: ‘‘ Will that be
all right if I walk up to the door and back again ? Will that be
USL LANS Dg
ARLE OS
FIG. 58.—PsEUDOGRAPHIA.
Portion of a letter by a patient suffering from dementia precox. He was
a sergeant and the disorder was ascribed to war-shock. The letter
was signed correctly.
all right if I walk up to the door and back again ? Will that be
all right if I walk up to the door and back again ?’’ and so on
ad infinitum. ‘“‘ Our own well, pussy’s in the well; who put her
in? Put her in ag’in. Our own well, pussy’s in the well; who
put her in? Put her in ag’in. Our own well, pussy’s in the
well...’ and so on. A patient who developed the stereotyped
antic of keeping her toes in constant movement while in bed, had
the following verbigeration: “‘ I can’t keep on twiddling my toes
like this for ever, I can’t keep on twiddling my toes like this for
ever, [icant keep on 3.) 6Les etcan
* The last patient quoted was depressed and made a complete recovery.
She was possibly a maniacal-depressive case, the “‘ twiddling”’ of the toes
being nothing more than a compelled peripheral movement of “‘ agitated
melancholia ’’.
PSYCHOLOGY OF DEMENTIA PRACOX Sb
With some patients only words or syllables are repeated. In
such a case the verbigeration resembles stuttering or stammering.
The judgment is frequently disordered so as to give rise to
delusions, especially in patients who are subject to hallucinations.
They may believe themselves to be watched or followed,
have delusions of persecution or exaltation or accuse themselves
wrongfully of past misdeeds. There is in fact no form of delusion
which may not arise in the course of dementia preecox; but as
mental deterioration and physical improvement proceed and the
patient becomes an apathetic dement these delusions recede into
the background and become forgotten, as do most symptoms of
the disease.
Psychopathology.—A broad view of dementia pracox gives
the impression that it is the fulfilment of an unconscious desire of
the patients who suffer from it to retire from the world of reality
to a world of their own creation. Hence they are said to be
“introverted ’”’. This wish to retire from the world into which
they have been born is in many cases exemplified by a tendency
to rest on “ bearing ”’ or “ carrying ”’ articles of furniture, which
in psycho-analytic experience we learn to be symbols of the
mother, or to creep into the solitude of small rooms, cupboards
or cavities, symbolical of the intra-uterine situation; some even
assume a prenatal attitude. The mother’s uterus is the most
comfortable place anybody has ever experienced.
So far as the receptive aspects of the mind are concerned,
there appears on the whole to be little disturbance. Perception,
cognition and recognition, ideation and memory are all fairly
good. The defect is mainly in the efferent functions; emotion
is paralyzed, while instinct and volition are ill-directed. The
patient performs extraordinary actions which appear to be
neither instinctive nor reflex; yet he tells us that they are beyond
the control of his will (that is—unconscious). It has therefore
been suggested that in this disease there is dissociation between
the afferent and efferent functions of the cortex. This view
receives support from the pathological discovery of Alzheimer
that there is gliosis of the deepest layers of the cortex, since
Lugaro has decided by a process of exclusion that the function
of the polymorphous cells of these deep layers is that of associat-
ing efferent with afferent impulses.
Stransky considers the essential psychical feature of dementia
precox to be a lack of co-ordination between the receptive and
affective functions of mentation, which he calls respectively
the ‘“‘noopsyche”’ and the “ thymopsyche’’. He calls this
332 MIND AND ITS DISORDERS
characteristic intrapsychic ataxia or noo-thymopsychic ataxia.
Accordingly the names ‘‘ Dementia sejunctiva’’ and “ Schizo-
phrenia ”’ have been suggested for this malady.
Clinical Varieties—The various forms of dementia precox
merge imperceptibly into one another, so that it is frequently
difficult to refer a given case to any particular one of the varieties
although the diagnosis of dementia preecox may be obvious.
Four varieties of the disease are recognized:
1. Simple dementia przecox.
2. Hebephrenia.
3. Katatonia.
4. Dementia paranoides.
Simple dementia preecox occurs in congenitally weak-minded
children before the twentieth year. It consists of a progressive
deterioration of the mental faculties, which is unaccompanied by
states of depression, excitement, stupor, delusion or hallucina-
tion. It is most frequently seen in idiot asylums. The patients
grow apathetic and idle, unable to concentrate their attention
upon customary pursuits and become demented in a year or less
from the onset of the disease; their activity is characterized by
mannerisms, negativism, Se daa and echolalia. This form of
dementia przecox is rare.
Hebephrenia, which is more common in men than in women,
usually makes its début before the twenty-fifth year. Two
sub-classes are to be distinguished; in one the chief symptom is
mental depression, while the other is characterized by motor
restlessness.
The depression of hebephrenia is commonly ushered in by such
premonitory symptoms as headache, general malaise and failure
of nutrition. The patient becomes shy, seclusive, solitary,
moody and depressed. He does not associate with his fellows,
loses all energy and desire for work and feels tired of life. Hence
determined attempts at suicide are frequent in this early stage
and the mode of suicide is rather liable to be somewhat bizarre;
for example, one patient attempted suicide by hanging himself
stark naked; another, a medical student, lay in a warm bath
and opened the external jugular, median basilic and internal
saphenous veins of both sides. Seclusiveness continues to show
itself after the patient has been admitted into an institution.
If the physician goes through his list of hebephreniacs after
he has made his morning round, he finds he has missed many
of those not confined to bed; they have been hiding.
HEBEPHRENIA 333
Hebephreniac depression differs from that of melancholia in
that it is unaccompanied by the rigidity characteristic of that
disorder and in being less persistent. Hebephreniacs momen-
tarily cheer up from their depression, have a good look at their
Fic. 59.—HEBEPHRENIAC SECLUSIVENESS.,
The patient is in the garden, locked out of the hospital; so she gets away
from other patients into a corner as close as she can to a small outhouse
(an uterine symbol). Symbolically she is saying, ‘‘ Let me get back into
my mother’s womb.”
surroundings, laugh in a childish senseless manner which is
almost characteristic of the condition and, if they believe them-
selves to be unobserved, run for a hundred yards or so along the
garden path.
At this stage a certain number of cases clear up and make for
334 MIND AND ITS DISORDERS
a partial or complete recovery; but, should the disease develop
further, symptoms similar to those of dementia paranoides make
their appearance. The patients think that people are making
disparaging remarks about them or they believe themselves to
be watched and followed by detectives or others. Then come
hallucinations, especially of hearing; more or less systematized
delusions follow in due course. A few of these patients subse-
quently become exalted.
In conduct they exhibit mannerisms and other symptoms
characteristic of dementia precox; they are untidy in their
dress, lounge about and talk to themselves. Their letters are
over-punctuated, verbose and stilted; phrases are frequently
repeated and words underlined.
During the whole of this period there is progressive mental
deterioration; the patient becomes more and more apathetic and
loses all capacity for work. As deterioration proceeds, hallucina-
tions sink into the background, delusions become forgotten and
within a couple of years he is a confirmed dement.
The restless cases differ but slightly from the depressed. The
characteristic laughter is more in evidence and the patients are
fairly contented and happy. They lounge about in comfortable
attitudes, but never remain for many minutes together in the
same place. They run the length of the ward to seek another
seat. They are not missed by the physician on his round like the
depressed patients, for they attract his attention by deliberately
running away whenever he approaches them.
Deterioration is more rapid in such cases. From the moment
of entry into an institution they begin to put on weight and in a
couple of months or so have become grossly fat. By the end of
six months the dementia is profound; they are “ wet and dirty ”’ in
their habits, totally incapable of looking after themselves, slovenly
in dress and they carry food to their mouths with the fingers.
Katatonia occurs rather more frequently in women than in
men, and at a slightly earlier age than hebephrenia. It is that
form of dementia preecox in which the motor symptoms, above
described as catatonia and catalepsy, are the chief characteristics.
Three forms have to be recognized: katatoniac depression, kata-
toniac stupor and katatoniac excitement.
Katatoniac depression is frequently mistaken in its early stages
for melancholia. After a premonitory stage in which there is
headache, loss of appetite, amenorrhcea and insomnia the patients
become depressed, anxious and unable to follow their usual
occupation. They are quiet and reserved and answer questions
KATATONIA 335
in monosyllables. Delusions develop rapidly; they accuse
themselves falsely of past misdeeds, believe that people in the
street insult them, either by actions or by word of mouth.
They are called by disgusting names or dung is thrown at
them.
Examination of the patient reveals diminution of the super- —
ficial and increase of the deep (tendon) reflexes, usually with
loss of sensation. Rigidity is a striking characteristic but differs
from the like symptom in melancholia in being uniformly dis-
tributed, the muscular tension involving not only the trunk,
shoulders and hips, but also the hands, feet and, in some cases,
the face (Snautz-krampf).
Negativism is shown by the patient’s refusal to speak (mutism)
and by his resistance to all kinds of interference. He refuses to
take food and has to be tube-fed, a procedure which frequently
induces some verbigerative form of speech; but apart from any
such interference verbigeration occurs from time to time, often
accompanied by mannerisms.
Katatoniac depression is the classical form of katatonia
described by Kahlbaum in 1872 and it is probably the most
favourable form of dementia praecox, some patients making an
apparently complete recovery, even after the disorder has lasted
for years. One of the author’s patients who was tube-fed for
nearly twelve months at the beginning of her illness, became
sufficiently manageable to return to her own home. There she
took no real interest in her surroundings. If given a dustpan and
broom, she would sweep the same patch of carpet for hours
together and it was impossible to maintain a rational conversa-
tion with her for any length of time. At the end of six years
more or less favourable reports began to be received and eight
years after she came under observation she made a complete
recovery, so far as the author was able to ascertain by the most
careful examination. Nevertheless the outlook for at least 75 per
cent. of these patients is a profound and progressive dementia.
Katatoniac stupor is occasionally preceded by a period of
depression; usually it starts de novo. After the customary pre-
monitory symptoms the patients become quiet and reserved and
gradually pass into a condition of negativism. During the early
stages there is peripheral analgesia (vide p. 117) which varies in
extent from day to day. There is good perception and hallu-
cinations are unusual, but they appear in a fair proportion of the
cases. The patients are neither depressed nor excited; they are
apathetic. Some, however, display a certain interest in their
336 MIND AND ITS DISORDERS
condition. For example, I have seen a patient take a surrep-
titious glance at her hands after their atavistic nature had been
demonstrated to a class of students. During the demonstration
the patient’s negativism prevented her from evincing interest
in the matter and even induced her to resist examination. |
If it is permissible to say that one form is more characteristic
of a disease than another, then it may be said of katatoniac
stupor that it is the most characteristic variety of dementia
preecox. It isin katatoniac stupor that atavistic signs and other
stigmata are most frequently encountered; it is in this form of
Fic. 60.—DEMENTIA PR#COX GROUP.
dementia precox that mannerisms, negativism, stereotypy, ver-
bigeration and automatic obedience (echopraxia and echolalia)
may be best studied.
The disorder has received the appellation “ stupor ”’ on account
of the immobility and mutism of the patients. They sit in a
lounging posture with their hands in their laps or stand apa-
thetically about corners of the ward. They cannot be induced to
speak (mutism) or at most they will answer questions in mono-
syllables or ask for their discharge in as few words as possible. It
must, however, be recognized that these patients are not cases of
truestupor. They know all that is going on around them and their
mutism and immobility are forms of negativism, not of paralysis...
KATATONIA 337
In many cases the limbs will remain in any attitude in which
they are placed (flexibilitas cerea) so that a typical patient might
serve as an excellent lay figure for an artist, were it not that his
negativism would cause him to move away.
Some are restless and wander up and down, in circles, spiral-
wise or like a caged animal. Any obstruction to these move-
ments is either eluded or forcibly resisted.
As in anergic stupor, some of these patients exhibit oedema of
the hands, feet and face, and the extremities are liable to be
abnormally cold and cyanosed.
Katatoniac excitement is usually preceded by one or other, or
-by both of the above varieties of katatonia. At first sight it bears
a superficial resemblance to acute mania, but on closer examina-
tion is found to differ from that state in many particulars.
There is usually some diminution of sensation in the hands.
Perception is normal, even in the most excited cases of kata-
‘tonia. The patients know their whereabouts and are commonly
able to give the date correctly. They recognize and know by name
the doctors and nurses. Memory for recent events is unimpaired.
It is, however, frequently very difficult to ascertain all these
facts about any given case on account of the patient’s inaccessi-
bility. His answers to questions are absolutely irrelevant;
whereas in acute mania the patient can usually be induced to
pull himself together momentarily to give a rational answer.
The conduct, too, of these patients differs from that of acute
maniacs in that they do not display excessive large-joint move-
ment. They clench their fists, rotate their forearms, pick their
bedding to pieces and perhaps throw it away. Nor is there the
same continuity of motor excitement; the movements of kata-
toniacs are sudden, impulsive, violent and reckless. They are
wantonly destructive; they tear clothing, smash windows and
articles of furniture, not in anger or for fun, but merely to do
that which will be objectionable; their destructiveness is a form
of negativism.
Negativism is displayed in other ways, such as refusal of food,
refusal to shake hands, averting the head and, in general, doing
the opposite of what is required.
The patients are “‘affected”’ in their behaviour; they make
grimaces, perform absurd antics and show signs of stereotypy
and catalepsy. They are dirty in their habits, expose themselves
indecently, adopt lascivious attitudes, apparently to annoy
others, and smear the walls of their rooms with saliva, urine
and feces.
ie
338 MIND AND ITS DISORDERS
Such behaviour is sufficient evidence of deficiency of emotional
tone and moral sentiment, even if further signs were wanting;
but they are not. These patients feel neither joy nor sorrow,
fear nor anger, anticipation nor satisfaction; and the meaningless
imbecile smile, which is too unfrequently seen, is accompanied ~
by no emotional feeling.
The speech is confused and more incoherent than in any case
of acute mania. It consists of disconnected words and phrases,
which are frequently repeated in the course of a single dia-
tribe (verbigeration) and the language is abusive and obscene
(coprolalia).
From the point of view of prognosis this is the most un-
favourable variety of katatonia. In the author’s experience it
is rare.
Dementia paranoides is a form of dementia przcox in which
hallucinations and delusions, especially of hearing and of perse-
cution, play the most important réle. The disorder is rather
more frequent in women than in men. Sixty per cent. of the
cases occur after the twenty-fifth year.
This variety is characterized by delusions of persecution and
of grandeur, which are constantly changing and associated with
mannerisms and other signs of dementia precox and at times with
mild states of excitement. The disorder may be preceded by
states of depression and stupor. Dementia supervenes within
two years, sometimes within six months, without remission.
Kraepelin distinguishes two varieties:
Dementia paranoides mitis, in which delusions develop as
above described and simple hallucinations dominate the subse-
quent clinical picture without causing profound disintegration
of the personality, and
Dementia paranoides gravis, a disorder of middle and later
life, which begins in the same way but leads later to a character-
istic dementia with emotional apathy and abnormal conduct.
Sensation is unimpaired and perception is good. Hallucina-
tions of hearing rapidly develop after a short incubation period
of shyness, seclusiveness and suspicion. The import of these
hallucinations is constantly changing and they form the basis of
correspondingly variable delusions. The same patient hears
mocking voices, proposals of marriage, invitations to leave the
asylum, insults, statements that somebody is waiting in the en-
trance porch for him, that poison is being secretly injected into
him, that his clothes have been stolen and are being sold at an
auction. He hears that he has obtained a title or some other
DEMENTIA PARANOIDES 339
distinction and suspects the attendants of attempting to appro-
priate it to themselves. In some cases the voices are referred to
telephones supposed to be in the wall and most absurd messages
are received over the wires; one patient, for instance, heard the
Austrian Emperor inviting him to drink paraldehyde with him.
Hallucinations and illusions of vision sometimes occur; usually
they take the form of faces and occasionally absurd visions are
seen. One patient, on entering the bathroom, saw the bath
suddenly stand up on end and lie down again. Hallucinations
of smell are not uncommon; they give rise to the notion that
poisonous vapours are instilled into the room. Similarly
gustatory hallucinations induce the idea that the mouth is filled
with objectionable matter.
During this stage patients become emotionally excited and
restless, in sympathy with the import of their hallucinations.
As the disease progresses hallucinations become less frequent
and delusions tend to be more expansive and more absurd. The
patients believe themselves to be capable of speaking hundreds
of languages, seeing people’s thoughts, creating worlds and
emitting light. The delusions change many times in the course
of an hour; but they are accepted and expressed without any
corresponding emotional feeling.
The patients grow incapable of mental work or continued
application to any form of physical labour and dementia becomes
confirmed in spite of comparatively good perception, orientation
and memory.
In his latest edition Kraepelin has multiplied his divisions of
dementia precox by recognizing depressed, excited, circular
and other forms as separate varieties; but these are all included
in the above description and classification, which appear to the
present writer to be more practically useful.
Course and Prognosis.—In the majority of cases, dementia
preecox proves to be a progressive disease leading to profound
dementia. Ina few cases the progress of the disorder is arrested
and the patient remains in a condition of partial dementia with
poverty of character, deficiency of judgment and reasoning power,
psychical apathy, loss of moral and, in general, limitation of the
mental horizon. There is failure of ambition and energy so
that he is satisfied to lead an idle life and become a parasite
on his friends and relations. University graduates are content
with manual labour on a farm; patients who have started on a
lower grade of intelligence become the victims of evil companion-
ship, the dupes of designing persons and perhaps take to drink.
340 MIND AND ITS DISORDERS
Recovery, apparently complete, takes place in a very small pro-
portion of cases. Lastly, there is an intermittent form of the
disease, in which the patient makes a fairly good recovery, then
relapses several times before dementia is sufficiently pronounced
for him to require permanent care inan asylum. In some cases
of this kind remission and intermission take place at short
intervals of a fortnight or a month. The intermissions are —
occasionally associated with menstruation. These cases are
sometimes erroneously regarded as maniacal-depressives.
Dementia preecox appearing for the first time after forty years
of age is incurable.
The severity of the symptoms is a very fallacious guide to
prognosis; some patients, who show but slight symptoms in the
early stage of this disease, sink steadily into dementia.
Prognosis differs slightly in the several varieties of dementia
precox. Kraepelin gives the following results of his statistical
investigations:
Of hebephreniacs 75 per cent. sink into profound dementia,
17 per cent. are but partially demented so that under super-
vision they are capable of a certain amount of useful work and
8 per cent. apparently recover.
Of katatoniacs 60 per cent. reach extreme dementia, 27 per
cent. are partially demented but sufficiently improved to justify
their being allowed to return home and 13 per cent. recover
at least temporarily.
In dementia paranoides recovery never takes place. Short
remissions occur infrequently, but the ultimate outlook is in-
variably hopeless.
Morbid Anatomy and Pathology.—The convolutional pattern
of the cortex is often abnormal, but otherwise the brain exhibits
no naked-eye changes.
With regard to microscopical appearances, Alzheimer, Sir
Frederick Mott and others have described areas of gliosis or glio-
matosis in the deeper layers of the cortex and Turner described
immature nerve-cells, one of which is figured in the accompanying
photomicrograph. In advanced cases there is widespread destruc-
tion of nerve-cells throughout the cortex, many being shrunken,
distorted and eroded at the margin. The nuclei also are shrunken
and dislocated and they stain deeply with methylene blue.
Several investigators, in fact all who have studied the matter,
have reported that the Abderhalden reaction in dementia praecox
is positive to the sex glands in at least half the cases, indicating
that destruction of these glands is an essential feature of the
PATHOLOGY OF DEMENTIA PR#COX 341
disease. It is not likely to prove the cause, because dementia
preecox is related by heredity to mental disorder, not to disease
of the ovaries or testes. Sir Frederick Mott has confirmed the
Abderhalden results by making a direct examination of the testes
post mortem in cases of dementia precox, and he has found,
both macroscopically and microscopically, regressive atrophic
changes of an extraordinary character in most of his cases.
The late Dr. Laura Forster, also working in his laboratory, found
regressive degenerative changes in the ovaries of many of these
patients; but also in those from other forms of mental diseases.
Dr. Noland, D. C. Lewis and others have made the observation
that the weight of heart in dementia precox is disproportionately
small, also that the aorta and larger arteries are of smaller lumen
than normal, and that their coats are thin. In seeking an explana-
tion for these phenomena he naturally turned to the endocrine
organs, and he found histopathological changes to be present
invariably in the thyroid, adrenals, and gonads (aplasias,
atrophies, scleroses and patchy hyperplasias).
The abnormal arrangements of the convolutions and the exist-
ence of immature nerve-cells both suggest an inherent structural
deficiency of the nervous system and there is an analogy between
these features and the atavistic stigmata described in the earlier
part of this chapter.
Jung, who has made a special study of the psychology of this
disorder, regards it as an “‘introversion’’; by which he means
that the patients, finding a difficulty in fitting themselves into
the world of reality, retire from it and live in a world of their own
creation. This notion is not inconsistent with the view that
they have reverted, both in bodily conformation and mental
characteristics, to a former era in the history of the race. Even
many of the symptoms (dirty habits, imitativeness, crawling on
all fours etc.) might be regarded as atavistic; but how are we to
explain the physical degeneration of the brain and other organs ?
In retiring from the world of reality and creating a world of
their own they escape many problems and mental conflicts but
meet many others in the process which require disentangling
and solving. As already stated, Jung is of the opinion that
this process is to be held responsible for the formation of toxins
which induce tissue degeneration.
For the present, therefore, we must adopt an agnostic position.
We do not even know whether dementia pracox is primarily
an organic or psychogenic disease.
Treatment.—Since the pathology of this disease is still some-
-342 MIND AND ITS DISORDERS
what obscure the treatment must, for the present, be merely
symptomatic. When the patient first comes under observation
he is almost invariably found to be suffering from malnutrition
and insomnia. Accordingly our first efforts are directed to in-
creasing his weight and procuring sleep. These results are to be
obtained in the same manner as in mania and melancholia. The
patient requires plenty of rest and the treatment must accord-
ingly be carried out in bed. The duration of bed-treatment
varies with the severity of the case. Mild cases of hebephrenia
and dementia paranoides may be allowed to get up for a few
hours each day after the lapse of a fortnight or three weeks.
Some severe cases of katatonia require rest in bed for six, nine
or even twelve months before a satisiactory state of nutrition is
achieved.
On account of the low blood-pressure in this disease Rae
Gibson advocates the administration of digitalis and strychnine
and Ishida recommends repeated injections of normal saline
solution (about 500 c.c. at a time). Both of these observers
record encouraging results.
It is possible that the patient may be ameliorated or even
cured in some cases by unearthing repressed complexes by
association experiments and other methods of psycho-analysis,
but the results have not up to the present been encouraging.
Unlike all other neurotics and psychotics, patients suffering
from dementia preecox do best in their own homes, at least
during the earlier stages. Degeneration appears to progress
more rapidly after they are sent to an asylum. It makes no
difference to the ultimate result; there comes a time when an
asylum is the only suitable place for such a patient, in his own
interests as well as those of the community.
Occupation is beneficial to patients suffering from dementia
paranoides.and mild forms of hebephrenia. Life in a colony for
the insane is well adapted to such patients; the time comes when
ordinary home life does not suit them. They are easily irritated
by people who do not understand them and, on the other hand,
they are usually very irritating to other people.
Some cases in America are said to have been improved after
excision of the thyroid gland. Further evidence must be forth-
coming before such a measure is likely to be attempted in this
country. It is difficult to see the rationale of the proceeding
and those reports which the author has seen are very uncon-
vincing. Similarly, he does not know why calcium lactate is
sometimes given as a routine medicine.
FIG. 61:—bWo BETZ. CELLS:
The one to the right shows a normal arrangement of its
Nissl bodies, and the nucleus is in a normal position. Inthe
upper part of the cell is a small collection of pigment. Note
that the axon and the eminence from which it springs are
devoid of Nissl bodies. .
The other cell issomewhat swollen, hasa displaced nucleus,
and the Nissl bodies are small dust-like particles. This re-
presents a defectively developed or immature form of cell,
found in idiocy, imbecility, epilepsy and dementia pracox.
(x 400.) [Negative kindly lent by Dr. John Turner of Brent-
wood Asylum.]
To face p. 340
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PARAPHRENIA.
PARAPHRENIA is the name applied by Kraepelin to a group of
delusional cases formerly classed under dementia paranoides,
or sometimes paranoia, but now brought together under a
separate heading for several clinical reasons.
The average age of incidence of paraphrenia is later than that
of dementia paranoides; it is usually during the fourth decade,
but in a few cases may occur as early as twenty-five or as late as
fifty or more years of age. Hallucinations develop much later
in the course of this disease than in that of dementia paranoides,
there is not the same destruction of the personality to justify the
appellation ‘‘ dementia ”’ and there are no catatonic or cataleptic
symptoms. The disorder occupies a place midway between
dementia precox and paranoia. It differs from the latter in
that hallucinations invariably occur sooner or later and the
delusions tend to be of a rather more bizarre character.
Etiology. Except for the age incidence the causative factors
of this malady have not been definitely established, but they
are practically identical with those of paranoia. ‘Indeed the case
of Dr. Schreber, whose autobiography was analyzed by Freud,
really belongs here rather than to true paranoia. About 60 per
cent. of the patients are men.
Symptoms.—There is no disturbance of sensation and, apart
from the hallucinations, perception is normal. Orientation is
good, the patients recognize people and things quite correctly
and their estimation of time is usually unimpaired; but I have
known patients of this class who would insist that the generally
accepted date was wrong by some days, weeks, months or years.
There is no disorder of memory and, unlike dementia preecox,
emotional reaction is normal.
Similarly the behaviour may be regarded as normal but for the
influence of delusions. The capacity for useful work is doubtless
diminished in the later stages of the disease, but entirely on
account of delusional preoccupation—the attention of patients
being directed more and more from their usual pursuits to.
343
344 MIND AND ITS DISORDERS
matters bearing on their phantasies. Insomnia is a frequent
complaint.
Paraphrenia is usually divisible into four well-marked stages.
The first is the period of “‘ false interpretation ’’. The patient,
whose normal mental attitude is one of suspicion, grows more
suspicious and distrustful; he sees hidden meanings in trivial
incidents. If people do not notice him as he goes to business,
it is because they wish to avoid him; if they look at him, it is
because they are detectives and he is under the surveillance of
the police. One man coughs to draw attention to the patient,
another blows his nose in order to conceal a smile with his hand-
kerchief and a boy whistles a mocking tune as he passes. In the
newspapers there are hidden references to his past life. One
patient detected obscure indications that the letter H and the
figure 8 had cabalistic significance for the Jesuits and Freemasons,
not only in modern literature, but also in the classics, and
thought that mankind in general, and himself in particular, were
being duped by concealment of the importance of these signs.
At this stage he may become depressed and despondent and
accuse himself falsely of having lived a life of sin. Other patients
complain to the police that they are being followed or persecuted
by some unknown person or they take to travel to escape their
enemies. Others again, of a more aggressive disposition, become
violent and strike passers-by whom they suppose to have in-
sulted them.
The second stage, which usually occurs some years later, is
characterized by the development of hallucinations of hearing,
which reinforce any previous ideas of persecution and help to
determine the character of the subsequent delusional state.
The profound impression created by these hallucinations cannot
be over-estimated. At first they may take the form of an
unintelligible babel of voices; later, isolated words are heard,
some being yet unintelligible, such as “ thiefist’’, ‘‘ death-
swivel’’, then ‘‘ murderer’’, ‘‘sodomite’’ etc. Then short
sentences are heard in which remarks (often untrue) are made
about the patient’s doings.
In some cases two voices or sets of voices are distinguished,
one accusing or annoying the patient, the other defending him,
accusations and insults being heard with one ear and friendly
remarks with the other.
The idea of friendliness or protection is welcomed by some
patients at this stage to such an extent that it displaces the
ideas of persecution and becomes the main element in the delu-:
PARAPHRENIA 345
sional state. Important persons may be fixed upon as their
guardian angel—the Lord Mayor, the King, the Pope, or even
the Kaiser.
Verbal psychomotor hallucinations are experienced by some
patients and give rise to the delusion that people are able to read
their thoughts. Olfactory and gustatory hallucinations, which
are not quite so common, induce corresponding delusions.
Hallucinations of the cutaneous senses occur with some
frequency and are often referred to by some neologism of the
patient; he complains that he is “ spreethed’’, “ torched ”’ or
‘“ cheefened ”’ at night or annoyed by “‘ the electric pin ”’.
Genital hallucinations, when they occur, induce the delusion
in women that they are pregnant or that they have been violated ;
and in men that they have been castrated, or that painful
erections have been caused by some base means.
Visual hallucinations are rare and, when they appear, the
patients at first seem to realize their true nature, at least to
such an extent that the course of the disease is unaffected by
their occurrence.
The persistence of these hallucinations and ideas of persecu-
tion gradually leads the patient to believe that he is the victim of
a systematic conspiracy to annoy him, or of a band of persecu-
tors, perhaps under the floor. Sometimes he fixes upon an
individual of his acquaintance as the cause of all his trouble. It
is in such cases as these that murder becomes an incident in the
disease and the case acquires medico-legal importance.
Very rarely remission may occur and the patient make an
apparent recovery during the first stage of the disease; but if
the second stage becomes well established, or the patient enters
upon the third about to be described, the prognosis is absolutely
hopeless.
The third stage is characterized by the development of delu-
sions of grandeur which gradually efface those of persecution.
Not all the cases, however, develop grandiose ideas. Authors
differ as to their frequency, but there appears to be little doubt
that at least half of these patients reach a stage of grandeur. It
may arise in one or more of three different ways:
I. Subconsciously the patient seeks a reason for his continued
persecution and comes to the conclusion that he must be some-
body of importance.
2. He hears himself referred to in hallucination as some great
personage. This is really “ putting the cart before the horse ’’;
because, after all, the hallucination is itself a creation of the
346 MIND AND ITS DISORDERS
patient’s own mind, the fulfilment of one of his unconscious
wishes.
3. An accidental occurrence, a misinterpreted conversation or
a chance resemblance observed by the patient between himself
and some magnate portrayed in the illustrated papers directs
his attention to the notion that he is an important individual.
One of the author’s patients observed a resemblance (a very
remote one) between himself and the Duke of Saxe-Coburg.
Thenceforward he believed himself to be of royal descent.
Another heard in hallucination the words “ His Majesty’.
From that moment he regarded himself as King Edward VII.
We must not allow ourselves to be misled into supposing that
this classification of the modes of origin of expansive delusions
offers any explanation of their occurrence. The main fact that
we have to realize is that it is in the nature of this disorder that
a stage of grandeur should develop in most cases, for we have
seen that the hallucinations and delusions tend to become
expansive even in dementia paranoides. The explanation of
this sequence of events is not quite clear; it would be interesting
to know if a sane individual, subjected to real persecution similar
to that from which these patients believe themselves to suffer,
would ultimately tend to become exalted.
When ideas of grandeur first begin to develop it is usually
a difficult matter to elicit them even by the most searching
examination. The patient remains reticent about them for
months; but when they are well established he is prepared to
give expression to them and even to reiterate them with untiring
monotony. It is sometimes possible to discern the incidence of
expansive delusions by a change in the patient’s behaviour. He
talks with a more self-confident air than hitherto, disdains his
relatives as being unworthy of him, carries himself with un-
mistakable hauteur, and gives stilted hints of his greatness.
Varieties.—Kraepelin describes four varieties of the disease.
He expresses the doubt that one of these (paraphrenia phan-
tastica) may really belong to dementia precox (paranoides) ;
but I know quite well the type of patient to which he refers
and can justify his opinion that these are not cases of dementia
preecox, but of paraphrenia. I add a fifth type to include Dr.
Steen’s “‘ chronic hallucinatory psychosis ”’.
Paraphrenia Systematica includes the majority of the patients.
It conforms in a general way to Magnan’s “ Délire chronique
ad évolution systematique’’, but does not lead to dementia. As
detailed above, delusions of persecution develop slowly and
VARIETIES OF PARAPHRENIA B47
systematically as in paranoia; but they are accompanied by
hallucinations. Delusions of grandeur may appear ultimately
and sometimes they are present from the beginning.
Paraphrenia Expansiva occurs almost exclusively in females.
Delusions of persecution and grandeur occur, but the latter
preponderate and the patients are in a chronic state of mild
excitement. Visual hallucinations predominate and, in about
half the cases, the substance of the megalomania is erotic.
Paraphrenia Confabulans is a rare variety which develops
rather rapidly. In my experience it usually occurs later in life
than the others; but—as I write—I have just seen a patient of
this kind aged 29. The chief characteristic is illusion of memory
with an extraordinary amount of confabulation. It is common
for the patients to claim noble birth, this being frequently based
on memories of early childhood. The above patient believes
herself to be Christ.
Paraphrenia Phantastica is less systematized than the above
varieties. Cutaneous hallucinations play an important réle and
take the form of bodily annoyance. Delusions of persecution
consequently arise, but these are more changeable than in
other forms of the disease. Neologism is common in this
type.
Paraphrenia ab hallucinatione.— Dr. Steen has drawn atten-
tion to a class of case in which the psychosis manifests itself
by hallucinations from the very beginning. At first the
patients apprehend the true nature of their hallucinations, but
this insight is gradually lost and delusions develop appar-
ently from them, the ultimate psychosis falling in line with
one or other of the above-mentioned varieties. I have there-
fore ventured to rename Dr. Steen’s ‘‘ chronic hallucinatory
psychosis ’’ in such a way as to indicate where I place it in
Kraepelin’s scheme of classification. Doubtless the cases might
be included in one of the above four varieties of paraphrenia, but
it is desirable to recognize the possibility that hallucinations
may be the very first symptom.
Course and Prognosis.—The prodromal stage of the disease is
_sometimes much prolonged, so it may b2 as long as six years
before a patient of this class is brought for medical advice. In
the meantime he has been carrying on his usual work quite
normally except that his associates have regarded him as peculiar
on account of his suspicious nature, irritability or other
symptoms.
Paraphrenia is essentially a progressive disease and, whilc it
348 MIND AND ITS DISORDERS
does not tend to shorten life, the ultimate outlook must be
regarded as hopeless. Paraphreniacs never recover.
Diagnosis.—Enough has already been said to indicate the
differences between this disease and dementia prcox or paranoia.
The only other malady which is likely to present any difficulty
in respect of differential diagnosis is chronic hallucinatory
insanity of alcoholic origin described on p. 413. The psychical
mechanisms of the two disorders are exactly the same; the only —
difference is that, in alcoholic cases, the poison has induced such
degeneration of the cortical neurons as to allow the homosexual
complex to escape the repression; but only partially, so that
the complex becomes manifested in symptomatic guise.
Treatment.—Since paraphrenia is an incurable disease, treat-
ment resolves itself into general management.
This consists of making the patients as comfortable and happy
as possible. In the long run this is almost invariably in asylum
care, but I know one patient of this class who, although an
asylum case for over a year at one time, has remained at large
and earned a meagre livelihood for many years in spite of persis-
tent symptoms. He has fought the battle of life with moderate
success; but I think that he would have been happier if he had
been secluded from the world all this time, as nearly all other
paraphreniacs are.
5 with paranoiacs, however, I like these patients to vee carry
’ to the best of their ability in the outside world, if they can
eae do so.
CT DT nex Te
EPILEPSY AND EPILEPTIC INSANITY.
“EPILEPSY is a disease characterized by occasional, sudden,
excessive, rapid local discharges of the cortical grey matter ’’;
but the name should not be applied to patients suffering from
the convulsions of alcoholism, plumbism, uremia, gross brain
lesions or general paralysis. Similarly, the practitioner must
not be too ready to jump to the conclusion that a patient
is suffering from epilepsy merely because a convulsion has
occurred; as sometimes happens episodically, for example, in
cases of dementia preecox or the anxiety neurosis. The above
definition, which owes its origin to Dr. Hughlings Jackson,
requires but little explanation. That the discharges are sudden,
excessive and rapid must be obvious to everybody who has
witnessed an epileptic fit. The epithet “ occasional ’’ was intro-
duced into the definition in order to exclude discharges which
are not occasional, such as the “interrupted continuous ”’ dis-
charges of chorea; and the epithet “local”’ is justified by the
fact that, while the characters of an epileptic fit differ in different
cases, they resemble one another in the same case. Each
individual patient invariably experiences the same aura and
invariably falls on the same spot of his body, e.g., the fore-
head or, more rarely, the occiput. With those whose fits are
ushered by a cry, the cry is invariably of the same character
for each patient; and if the tongue is bitten, it is in exactly the
same spot in each successive fit. Lastly, and this is the point
which most concerns those who have to deal with mental disease,
if the patient is liable to an attack of mental disturbance before
or after each fit, the nature of the mental disturbance is the
same in successive attacks. |
Etiology.—By far the most common cause of epilepsy is
hereditary predisposition. Kraepelin obtains a history of
nervous disease in no less than 80 per cent. of his cases and
of epilepsy in the parents in 25 per cent. Epileptics almost
invariably have some stigmata of degeneration. Cranial and
349
350 MIND AND ITS DISORDERS
facial asymmetries, deformities of the palate and ears, microph-
thalmos, microcephaly and prognathism are among the most
common malformations.
Alcoholism in the parents is commonly believed to be one of
the causes of epilepsy. Such a belief does not necessitate the — |
acceptance of the doctrine of heredity of acquired characters,
but rather that the inclination to intemperance is a sign of
neurotic tendencies and that the parent’s abnormal behaviour
during the childhood of the patient has had a profound evil
influence on his personality. It is more certain that alcoholism
in the patient may give rise to epileptic fits.
_ Seventy-five per cent. of the cases begin before twenty years
of age and 16 per cent. between twenty and thirty. Males and
females are equally liable to the disease, except in later life,
when the incidence is rather greater in males.
A certain number of cases date’ from some head injury or are
dependent upon a cerebral lesion of vascular or syphilitic origin.
Under this heading are to be reckoned the epilepsies due to
“ birth palsy ”’
Scarlet fever appears to be responsible for a few cases, the
first fit occurring in the course of or immediately after an attack
of this disease. Predisposition is probably the most potent
factor in the causation of these cases and also of those which
are ascribed to irritation arising from normal dentition, carious
teeth or intestinal worms.
Epileptic insanity rarely, if ever, develops before the epilepsy
has been of long standing and patients often retain their full
mental vigour although they have been subject to fits for many
years. Julius Caesar, Mahomet, Peter the Great and Napoleon I.
are the usual classical examples, but in all of these cases the fits
appear to have been rather infrequent.
The main factor which determines the incidence of epileptic
insanity appears to be frequent recurrence, rather than severity
of the convulsions; indeed, it has been pointed out by many
authors that insanity is more liable to occur in patients who
are subject to attacks of minor epilepsy than in those who suffer
from major epilepsy only. It has been said that insanity is
liable to develop soon when the epilepsy begins late in life, but
I do not agree with this dictum.
As will be seen later there is good ground for the belief that
some sort of toxemia is directly responsible for the more striking
manifestations of this disease; but psycho-analytic investiga-
tions afford very strong evidence in favour of the view that the
THE EPILEPTIC CHARACTER Bees
primary factors of epilepsy are purely mental and that all
the observed physical characteristics are secondary to these.
Hitherto, in spite of the wealth of material for study and the
devotion and many discoveries of countless eminent physicians
and pathologists to its investigation, the ultimate cause of
“idiopathic ”’ epilepsy has remained a hidden mystery.
In recent years, however, much light has been thrown on
the real nature of this disease by psycho-analytical studies of
epileptics, especially by Pierce Clark in America and by Ferenczi
and Maeder on the continent of Europe. To such superficial
observers as we have all been in the past, the convulsion is the
most striking and important feature of epilepsy, but the above
psychologists have demonstrated that. the mental make-up of
the patient in whom the convulsion occurs is of much greater
fundamental importance. In other words, epileptic fits are only
a part of the epileptic character. This statement is likewise
applicable to some of the organic epilepsies, such as those of
infantile hemiplegia and diplegia, alcoholism etc., the lesion
merely permitting the epileptic character to assert itself.
The Epileptic Character.—It is desirable to consider the mental
characteristics of the chronic epileptic also because these may
be of practical diagnostic significance, seeing that some hysterical
and other convulsions are often indistinguishable from those of
true epilepsy—to such an extent that I am in the habit of
speaking of that condition as ‘“‘ psychogenetic epilepsy ”’ without
losing sight of the fact that all epilepsy is really psychogenetic.
Moreover, the study of the epileptic character demonstrates
epilepsy to be essentially a mental disease—a fact which is liable
to become minimized by or forgotten on account of the maze of
important pathological findings, especially the changes in the
composition of the blood.
Apart from the tendency of true epilepsy gradually to reduce
the intellectual capacity, even to apparently extreme dementia
in many cases, the patients suffer from poverty of ideation and
sluggish mentality similar to that of a child of four or five years
of age. Indeed this mental infantilism is the keynote of all the
mental characteristics of the epileptic. He has a small vocabu-
lary and Jung reports that he finds that the word-reactions (vide
Pp. 53) are like those of children or imbeciles. The patients are
self-centred; they attach undue importance to their own activi-
ties, however childish and unimportant these may be; they tend
to forget matters of general interest and knowledge and to re-
member only those of personal interest, they feel that their
352 MIND AND ITS DISORDERS
personality should be of as much interest to others and the
discovery that it is not may lead to delusions of persecution ;
there is often a certain amount of vanity exhibited in their dress—
at any rate they are especially pleased with uniforms or decora-
tions of various kinds; they pay unnecessary attention to their —
bodily health, especially with regard to actions of the bowels
and any slight discomfort about the anus—a small hemorrhoid
is sure to claim plenty of attention. There is a rise of the egoistic
sentiments and decline of the altruistic; epileptics try to get
others into trouble and to obtain sympathy for themselves.
Hence we find that it is in the epileptic ward that most of the
charges of cruelty to patients have to be investigated; for
example, a patient accuses an attendant of having struck him
and exhibits a self-inflicted bruise to substantiate the charge.
The conduct of the epileptic is peculiarly brutal and ferocious;
if he is offended, he reacts with wholly disproportionate violence,
and murder is one of his instincts.
The remarkable degree of religiosity of the epileptic appears at
first sight to be paradoxical to such a character as we have
portrayed. Night and morning he reads his Bible, sings hymns
for all to hear and, like the typical Pharisee, falls upon his knees
in prayer at opportune and inopportune moments in public.
This is probably the expression of an infantile desire for de-
pendence on “ the father ’’, as Gallus has suggested.
At adolescence the sexual instinct is uncontrolled and the
patient takes to masturbation or commits other unnatural sexual
offences. His instincts are criminal, a fact recognized by the
prison authorities who make ample provision for epileptics in
the form of padded rooms, etc., in all the larger prisons. More-
over, the remarkable frequency of sexual offences as “ epileptic
equivalents ’’ hereinafter described, suggests that the sexual
instinct plays an important rdle in this disease.
It is not difficult to discern an auto-erotic basis and narcis-
sistic tendency in the epileptic character above outlined; but
this is not all. During an “epileptic equivalent ’’ when the
patient’s normal consciousness is in abeyance and his uncon-
scious personality holds uncontrolled sway, he is liable to commit
violent sexual aggressions which are usually of a perverse nature,
such as exhibitionism, homosexual advances and so forth,
although they are sometimes of a more normal character. Even
apart from definite epileptic attacks these patients are apt to
become sexually turbulent and violent in abnormal ways, the
normal channels of outlet being insufficient to satisfy their
THE EPILEPTIC CHARACTER 353
libido. Such observations bring us back to the same conclusion
—that the epileptic character is infantile, the sexual tendency
being “ polymorph-perverse ’’, to use Freud’s expression, just
as in the normal child.
In most asylums, probably in all, the inmates of the epileptic
ward are generally regarded as being potentially ‘“‘ dangerous ’’.
Their instincts are criminal, but it must be admitted that a few
of these patients are good-tempered when at their best and will
assist the attendants in nursing the more troublesome patients.
Even this feature is probably an infantile characteristic, for
children like to identify themselves with their mother and to
help her in something she is doing. At least those readers who
are familiar with psycho-analysis will discern the possibility
that to the unconscious mind of the patient the attendant may
symbolize the mother.
With very few exceptions, an epileptic can tell us nothing of
his thoughts occurring in association with or during a full-blown
convulsion; but, after an attack of petit mal, he can frequently
give some account of his mentality. Such reports, as well as
the dreams of epileptics, afford evidence that the purpose of
the fit is of a twofold nature, viz., (1) To gratify sexual desire
vid muscular and respiratory activities (orgasm), and (2) to
retreat from the world of reality vid unconsciousness. This last
is really the fulfilment of a wish to return to the prenatal state
(metro-erotism of Pierce Clark); indeed a few epileptics after
a fit have made the definite statement that they have been in
their mother’s womb. He is not only infantile; he desires to
be still more so.
The mental infantilism of the epileptic is especially striking
in the domain of sexuality. In females the menstruation is late
and scanty, in males nocturnal emissions do not occur before
eighteen or nineteen years of age and masturbation persists long
after marriage. In later life the menopause occurs early, and
in males there is a tendency to handle the genitalia without any
attempt to provoke emission—just like a child.
Should the mother pass out of the patient’s life, by death or
otherwise, the transference to some surrogate, such as an elder
sister or a nurse, occurs almost immediately. The patient is in
constant search for mental shelter and, when he fails to find it,
the accumulation of displeasure affects finds relief in a paroxysm,
just as children react to unpleasant situations by kicking,
screaming, stamping their feet and so forth.
This infantile character antedates the occurrence of the first
23
354 MIND AND ITS DISORDERS
epileptic fit and there is plenty of evidence to show that the
emotional defect is due to psycho-sexual immaturity. Our
conclusion from all these considerations is that the convulsion,
about to be described, must be regarded as a secondary charac- _
teristic of the disease. | 3
Dr. Scripture has demonstrated a curious physical phenomenon
which is probably of psychical origin. His patients are directed
to speak into an apparatus connected with a revolving drum on
which are recorded the strength of the puffs emitted during
vocalization. A line connecting the tops of the ordinates shows
what he calls the ‘“‘melody plot’’. In a normal person the
melody is a variable rise and fall, but in epilepsy the vowels run
along in an even tone—“ plateau speech”’. Dr. Scripture
ascribes this to the slowness and deliberateness of the epileptic.
With practice it is possible to detect by direct observation this
peculiarity of the epileptic voice.
Preparoxysmal Stage.—When an insane epileptic is about to
have a fit, an experienced attendant is usually able to detect
a characteristic change in the patient’s conduct for a couple of
days or so before the convulsion. He is restless and sleepless
and his customary impulsiveness is exaggerated. He may
become bad-tempered, gloomy and unable to follow his usual
asylum occupation; he may be suspicious with delusions of per-
secution or elated with delusions of grandeur or a true maniacal
attack may be observed.
Prodromal Stage.—This stage lasts from a few seconds to
three minutes previous to the onset of the fit. It is in reality
the beginning of the convulsion and is characterized by the
appearance of the aura or warning, which is usually of a sensory
nature. Warning does not come in all cases and is less common
in insane than in sane epileptics.
The epigastric aura, which consists of a feeling of oppression
in the epigastrium, is the commonest. Most patients describe
the sensation as travelling from the epigastrium up to the throat
or into the head. Visual aure consist of hallucinatory appari-
tions of people, either singly or in crowds, motionless or in move-
ment. One patient used to see his own face, and address it:
“Hallo, Fred! Is that you?’ Other patients experience
visions of angels in the heavens or devils in hell. Frequently
the hallucinations are less complex and appear as stars, sparks
of fire or coloured lights.
Auditory aure are less common and when they occur are
usually crude, such as whistling or hissing in the ears, a crash
EPILEPTIC AURE 555
or a crack inside the head. Occasionally the aura consists of
music or the ringing of church bells, the sexual significance of
which is well known to psycho-analysts. Gustatory aure are
not very common; they are usually unpleasant and accompanied
by champing movements of the mouth. Olfactory aure are
rather more common: when present, the patient experiences an
unpleasant odour, usually of something burning, chemical fumes
or decomposing animal matter. Hughlings Jackson pointed out
that the olfactory aura is frequently accompanied by a “‘ dreamy ”’
state in which the patient has a sense of unreality of his sur-
roundings. Occasionally the aura is motor, the patient running
a short distance or turning round two or three times before
falling unconscious in a fit. Other premonitions are a sense of
fear, shivering, vomiting and an increased flow of saliva or sweat.
A motor aura must obviously be regarded as the very begin-
ning of the motor convulsion. Sensory aure give a clue in
organic cases to the site of the discharging focus in the cortex.
I have suggested that, in some cases, the physical basis of a
premonitory hallucination may be the last part of the sensory
cortex to be affected. For example, a patient suffering from
the epigastric aura is on the road to unconsciousness, otherwise
loss of sensation; and my suggestion is that, during the aura,
loss of sensation has already begun in the limbs and that the
epigastrium dominates consciousness because it is the last region
to become anesthetic.*
The Convulsion.—Simultaneously with the loss of conscious-
ness the pulse becomes feeble and occasionally ceases altogether
during the early part of the tonic stage, the face is bluish and
the patient falls to the ground convulsed. The march of the
spasm is so rapid that it is impossible to say which is the first
muscle affected. To all appearance every muscle in the body
contracts vigorously at the same moment. There is, to use
Hughlings Jackson’s phrase, a “‘ clotted mass of movements ”’.
That there 7s a definite order of spasm is obvious from the fact
that different patients fall in different ways and each patient
falls in the same way in successive fits, and Dr. Pierce Clark
has been able in some cases to trace the attitude usually assumed
during a fit to some situation of affective significance occurring
during the patient’s childhood.
As a rule the spasm is stronger on one side of the body than
* Since writing the above Dr. Collins, formerly superintendent of the
L.C.C, Epileptic Colony, has discovered peripheral anesthesia in an epileptic
during a prolonged aura.
356 MIND AND ITS DISORDERS
on the other so that the head, eyes and mouth are drawn to
one side. Should the contraction of the chest muscles happen
to coincide with closure of the glottis, as it frequently does, a
peculiar cry occurs as the patient falls. The elbows and wrists
are slightly flexed and the hands clenched upon the thumbs;
the lower limbs are commonly extended. The face becomes
cyanosed owing to fixation of the chest. Urine is voided with
such force as to suggest that the bladder muscles are involved
in the spasm. This condition of affairs, which is known as the
“tonic stage’”’, lasts about half a minute, at the end of which
time the muscles momentarily relax, at first every few seconds,
then more and more frequently. These relaxations become
more and more prolonged and the intervening spasms shorter.
In this, which is known as the “ clonic stage’”’, the convulsion
appears as a series of jerks or spasms involving the whole body.
At first the jerks are due to momentary synchronous relaxa-
tions and later to momentary synchronous contractions of all the
muscles of the body. It is usually in this stage, which lasts about
one minute, that the tongue is bitten. An onlooker has there-
fore sufficient time to obtain a tongue-depressor, spoon or similar
implement to prevent this accident by sliding, for example,
the handle of a spoon between the teeth on the first re-
laxation and gently depressing the tongue until the convulsion
is over.
Some patients are liable to a series of five, ten or more up
to 200 such fits without recovering consciousness in the intervals
(status epilepticus). In this condition the temperature usually
rises three or four degrees and the patient is reduced to a state
of extreme exhaustion which may terminate fatally.
During a convulsion all the superficial and tendon reflexes
are in abeyance and cannot be obtained. After the fit the
patient is exhausted and commonly sleeps for a quarter of an
hour or so. This sleep is to be regarded as analogous to the local
paralysis which occurs after a local fit arising from a lesion of
the precentral gyrus. It is temporary universal paralysis.
That this exhaustion is not only of the cerebral cortex, but also
of lower nerve centres, is shown by the fact that in most cases
the knee-jerk is diminished or absent.
Defendorf reports that he made 1,088 observations on the
state of the reflexes after epileptic fits. ‘“‘ The normal plantar
reflex (flexion of the toes etc.) was present in both feet immedi-
ately after clonus had ceased in 45 cases, and one hour later
in 226 cases; the Babinski phenomenon (extension of toes with
EPILEPTIC FITS Sy
dorsiflexion of ankle) occurred in 103 cases directly after seizure,
and in 112 cases one hour later. An extensor response was
found in right or left foot in 99 and 53 cases respectively, and a
flexor response in right or left foot in 99 and 211 cases respec-
tively; while a mixed response, that is, extension in one foot
and flexion in the other, occurred in 82 cases directly after a
seizure, and in 147 cases one hour later. The plantar reflex
was abolished in 660 cases immediately after the convulsion, and
in 339 cases one hour later. The knee-jerks were active in
396 cases, moderate in 137, and absent in 539 cases.”’
Epileptic attacks usually occur at intervals of two or three
weeks, but their frequency varies enormously. One patient of
mine, not insane, has had four convulsions in about twenty-five
years. Another, also not insane, who had been subject to
attacks about once a month, had no fit for ten years, during
which time she had taken bromide regularly. She then ventured
to leave off her bromide and at once had a fit. Brown-Séquard
had a patient who had fits nightly for seventeen years and an
average of twelve nightly for ten years.
Many patients are liable to batches of fits, not status epilep-
ticus; they have five or ten fits in the course of two or three
days, go a couple of months without any attacks, then have
another batch and so on.
Not all epileptic attacks are as severe as the major attack
above described. Sometimes muscular spasm occurs of such
brief duration that it is unobserved by an onlooker, sometimes
it lasts just long enough to be noticeable. In other cases the
patient perhaps experiences an aura, momentarily loses con-
sciousness and lets some object in his hand fall to the ground
or even falls himself; but the attack appears to be unaccom-
panied by muscular spasm. All these cases are classed as ‘‘ minor .
epilepsy ’’ or petit mal. Hughlings Jackson pointed out that
the physical basis of such attacks is in the functionally highest
regions of the cortex which we now call “ association areas ’’ and
that it is because the disorder in these cases is of the areas which
constitute the physical basis of mind that minor epilepsy is
especially associated with and liable to induce insanity; but we
shall have to regard this as too materialistic a view of the disease
if it is ultimately proved to be of purely mental origin—as seems
probable. These minor attacks receive various names in popular
parlance. Sometimes they are spoken of as “‘ faints’’, a term
which will mislead only the most casual practitioner. Among
asylum attendants they are usually called “‘ sensations ”’
358 MIND AND ITS DISORDERS
Post-Epileptic Automatism.—It is especially after these minor
fits that the condition known as post-epileptic automatism is
likely to occur. The patient has a minor attack and imme-
diately proceeds to perform some apparently purposive action of
an irrelevant nature. For example, he may proceed to undress
in the public street; this is quite common. I doubt whether
anybody ever seriously accepted Sir William Gowers’s explana- —
tion that it occurred on account of some vague sense of indis-
position and the propriety of going to bed. We now recognize
it to be the gratification of an unconscious desire to expose the
body to public gaze. Many instances of automatism have been
recorded. ‘‘ One man drove a waggon across London, and found
himself six miles from the place where he was, as it seemed to him,
a moment before’’ (Gowers). A bank clerk was sent on an errand
to another bank, having entered which, he knocked a clerk off
his stool, disarranged some papers but removed none and left
the bank. Subsequently he remembered nothing of the incident
except experiencing his usual epileptic aura on ascending the
bank-steps. Then there is the classical case of the French
judge who, after an attack of petit mal which occurred during
a trial, micturated in the corner of his court before the public
gaze, an incident of which he could subsequently recollect
nothing. Occasionally, however, these post-epileptic states are
remembered by the patient. A man, who worked in a ship-
yard and had for some years been subject to attacks of “ giddi-
ness ’’ with increasing frequency, went to the yard as usual
one morning, worked for half an hour, then went and sat on a
piece of timber. His comrades spoke to him but could get no
answer, so he was taken to hospital. While there he would
say nothing except the Lord’s Prayer, in reciting which he
showed some difficulty of articulation. After a sojourn of a
few days he was transferred to an asylum where he became
almost immediately his normal self and was able to recount
all that had happened to him in hospital, knew the names of
the doctors there and related incidents which occurred during
demonstrations of his case to the students. After a few days
he relapsed and became an ordinary case of epileptic insanity.
All such incidents would, or rather should, be subjected nowadays
to analysis.
Epileptic Equivalents.—States of automatism similar to the
above sometimes occur independently of epileptic convulsion,
major or minor. Such states are then regarded as substitutes
for epileptic fits and are known as “ epileptic equivalents’. Of
EPILEPTIC EQUIVALENTS 359
these there are two varieties, the transient and the protracted.
Both are almost always, but not invariably, characterized by
subsequent loss of memory of the events which have taken
place during the attack.
The transient equivalent lasts from a few seconds to a few
hours, rarely longer, and consists of an isolated impulsive act
usually of a violent nature. One form of impulse is the “‘ epileptic
flight ’’, in which the patient runs for ten or even twenty miles as
if impelled by an irresistible force and perhaps strikes anybody
who happens to be in his way. With some patients the flight
takes place to the same spot in successive attacks. More
commonly the impulse consists of a violent, occasionally mur-
derous, attack. In other cases the criminal impulse is of a
less violent nature, such as indecent exposure, arson or theft.
Not infrequently these transient equivalents are immediately suc-
ceeded by such post-epileptic phenomena as headache and sleep.
Protracted equivalents last from a couple of days to two
months. These are the attacks of true epileptic insanity most
commonly seen in asylums.
Under this heading we have to consider:
Epileptic depression or ill-humour;
Epileptic excitement;
Epileptic confusion; .
Epileptic delirium;
Epileptic stupor (so-called epileptic catatonia) and
,
Epileptic automatism or ‘‘ double consciousness ”’.
In epileptic depression the patient is dominated by a feeling
that his surroundings are hostile. The condition resembles
melancholia in which the patient regards his incapacity as
being due to an increase of the resistance of his environment.
He is irritable and querulous. He complains of everything, of
the inferior quality of his food, of the antagonism of fellow-
patients, of cruelty of the attendants and want of sympathy on
the part of the doctor. He complains of headache, epigastric
oppression, loss of appetite, bowel obstruction and a host of
other physical ailments. He threatens or attempts suicide and
requires the most careful supervision.
Epileptic excitement is characterized by extreme intensity and
severity, such as is rarely met in other forms of insanity.
The aspect of the patient is forbidding; the face is pale or livid,
the eyes staring, the facial expression either absent or indicative
of readiness for attack. The movements are impulsive and
360 MIND AND ITS DISORDERS
violent; the patient makes mad rushes at the attendants or, if
restrained, struggles blindly and furiously. This is the classical
type of epileptic excitement which has received the name of
‘epileptic furor’. The patient is either silent or garrulous and
incoherent. |
Nevertheless he is not entirely inaccessible; he can occasion-
ally be induced to answer questions, but immediately relapses _
into incoherent babble. Criminal acts, such as suicide, homicide
and crimes of a sexual nature, are liable to be committed in
this condition.
Not all cases of this epileptic excitement exhibit such
passionate fury and violence. Some laugh convulsively, strip,
turn somersaults, declaim or address irrational remarks to
bystanders or to pictures on the wall. The disorder lasts from a
few hours to a couple of days and is one of the states which have
received the name of “ mania transitoria’’. As such nomen-
clature is rather misleading, it is better that the term be allowed
to drop.
Epileptic confusion is a remarkable state in which the patient
suffers from peripheral anesthesia, usually of extensive distribu-
tion, imperception and disorientation accompanied by aimless
wanderings and purposeless movements of the arms and legs.
The patient cannot understand simple commands or appreciate
the nature of his environment (imperception and disorientation).
Occasionally a relevant answer can, by persistence, be obtained
to simple questions. One patient in a London hospital told me
that she knew she was somewhere near the sea because she could
hear the sound of the waves; she really heard the noise of the
traffic. This patient showed a certain amount of suggesti-
bility. After demonstrating the case to a class of students I
suggested that in about a week’s time she might possibly hear
a crack in her head and suddenly recover. One week later,
almost to the very minute, the patient heard a crack in her head
and returned to her normal condition. The kudos I then
obtained for remarkably clear insight into the patient’s malady
was ill-deserved. The result was probably to be explained by
the patient’s unsuspected suggestibility; it could hardly be a
coincidence.
The unique case of allocheiria of epileptic origin, mentioned on
p- 123, occurred in a patient suffering from epileptic confusion
of this nature.
Epileptic Delirium.—The predominant characteristic of this
form is the presence of terrifying hallucinations. The patients
EPILEPTIC EQUIVALENTS 361
see devils, animals, fire, blood or infernal machines destined to
torture them. They believe themselves to be surrounded by
enemies and they attack bystanders with intent to kill them.
In some cases the hallucinations have a religious import; God,
Christ and the angels appear to them in the heavens and perhaps
speak to them. Such hallucinations may induce the patient to
sing hymns or fall on his knees in prayer. These patients are
completely disorientated and apparently suffer from impercep-
tion, but it is difficult to test this point on account of their
general dread of everything and their consequent motor ex-
citement.
In epileptic stupor there is extensive peripheral analgesia and,
I believe, contraction of the visual fields. The pupils are dilated
and react but feebly to light. The patients stand rigidly in
one position, apparently oblivious of their surroundings; they
assume catatoniac attitudes and flexibilitas cerea is not un-
common. Usually they take no notice of external stimuli, but
occasionally they resent interference and even strike passers-by
impulsively. They are “ wet and dirty ” in their habits.
Some take their food mechanically, others refuse all nourish-
ment and require artificial feeding. Speech is absent or con-
sists of irrelevant detached words and phrases uttered in a
tone devoid of emotions; the patients do not respond to questions,
probably in part because they do not understand them (im-
perception).
Epileptic Automatism.—In this state patients may commit
extravagant, perhaps criminal, acts similar to those mentioned
under the heading of post-epileptic automatism. Not infre-
quently, however, they behave in an apparently normal and
rational manner so that their condition is unsuspected. They
perform unpremeditated complex actions of which they have
no subsequent remembrance. The patient may forget his own
name and even change his identity (double consciousness). The
most striking instances are those in which a long journey is
undertaken, the case being then reported in the lay press as a
“ mysterious disappearance.”
Legrand du Saulle has related the case of a merchant who, on
recovering from his attack, found himself on the way to Bombay.
Dr. W. S. Colman has told me of a guardsman, quartered in
a London barracks, who suddenly heard a crack in his head and
found himself in Newton Abbot having unintentionally absented
himself without leave. Perhaps the most remarkable case of all
is that of the Rev. Ansel Bourne, mentioned by Professor James.
362 MIND AND ITS DISORDERS
This patient, who was an itinerant preacher, disappeared on
January 17, 1887, and did not recover until March 14 of the same
year when he found himself keeping a confectioner’s shop under
the name of A. J. Brown in Norristown, Pennsylvania, 200 miles
away. During the whole of the attack nobody in Norristown
ever suspected that there was anything wrong with the man.
The duration of these attacks of so-called “‘ psychic epilepsy ”’
is from a few hours to a couple of months. Recovery may ~
be gradual or sudden, sometimes after prolonged sleep. There
are cases of sudden recovery in which the patient at the moment
of awakening hears a crack in his head. What this crack may
be opens a wide field for speculation. The whole period during
which the epileptic equivalent lasts is usually covered by com-
plete, sometimes by partial, amnesia. Occasionally, on the other
hand, the patient can remember everything that has occurred,
as in the case of epileptic confusion above cited. Not all cases
of double consciousness. are epileptic in origin; some are un-
doubtedly hysterical.
Narcolepsy, a condition of deep sleep lasting sixteen to twenty
hours, sometimes occurs as an epileptic equivalent. It is followed
in some instances by mild attacks of excitement.
Post-Epileptic Insanity.—After an epileptic has had a convul-
sion he is liable to attacks of mental disorder differing in no way
from the epileptic equivalents above described. The question
arises whether the so-called equivalents are not invariably pre-
ceded by an attack of petit mal, so slight as to escape observation.
I am convinced that this is so in a large number of the cases.
Whether it is always so is a matter which, in all probability, can
never be definitely settled.
Epileptic Dementia.—In the course of time the repeated con-
vulsions and attacks of true epileptic insanity begin to leave
their apparently permanent mark upon the patient’s mentation
and he becomes weak-minded. At first there is poverty of
ideation, fallacious judgment, faulty memory, emotional in-
stability and deficiency of moral tone. He is cruel to other
patients and deceitful to doctors and attendants. He is irritable,
vindictive, malicious and liable to unprovoked outbursts of
anger. His look is uncertain, furtive and “ metallic ’’.
His vocabulary becomes so impoverished that he has to express
himself in circumlocutions. In narrating incidents he wanders
off in long digressions and enters into unnecessary detail. On
the other hand, he has difficulty in understanding the language
of others (imperception).
EPILEPTIC DEMENTIA 363
When dementia becomes more pronounced the patient is com-
pletely disorientated in time and place, imperception is complete
and memory annihilated. He sits huddled up in a corner of the
ward, is wet and dirty and leads a purely vegetative existence.
The dementia may be as profound as that produced by general
paralysis. Anesthesia of the hands is not uncommon in this
condition. Nystagmus may occasionally be observed.
The general disposition of epileptic dements is morose and
suspicious and a few develop systematized delusions of persecu-
tion. Hallucinations are rather uncommon at this stage.
In spite of the apparent profundity of this dementia Dr. Pierce
Clark has shown that it is not a true dementia, for he has suc-
ceeded by his methods of treatment in alleviating it and even,
in some such cases, completely curing the disease.
Prognosis.—The earlier the age of incidence of epilepsy, the
graver the prognosis. Children who develop epileptic fits before
the age of seven are destined to become epileptic idiots incapable
of education. This matter is dealt with in another part of the
book.
The more frequent the convulsions and the longer the duration
of the disease, the smaller is the probability of permanent
recovery and the greater the probability of subsequent insanity.
According to Gowers, the prognosis is better when the attacks
are limited to either the day or night than when they occur in
both sleeping and waking states.
Attacks of minor epilepsy are of grave significance because
they are more difficult of arrest by treatment than major attacks
and because minor attacks are more liable than major to become
associated with epileptic insanity.
The prognosis of epilepsy is unfavourable when the disease is
induced by cerebral injury or a scar of some former cortical
lesion.
More important than any of the above factors in the prognosis
of the disease is the treatment. This depends very largely upon
whether the circumstances of the patient will allow of treatment
being satisfactorily carried out. Ceteris paribus, if, during the
early stages of the disease, the attacks are completely arrested
by treatment for a period of two years, the chances of recovery
are fairly good, recovery meaning freedom from attacks without
treatment. These remarks apply equally to epileptic convul-
sions, epileptic equivalents and other forms of epileptic insanity.
Even in the early stages of epileptic dementia the beneficial effects
of careful medicinal treatment (vide infra) may be observed.
364 MIND AND ITS DISORDERS
Morbid Anatomy and Pathology.—The most striking features
in the morbid anatomy of an epileptic are teratological anomalies,
not only cranial, facial and other asymmetries, but alterations in
the modes of convolution of the brain. Further, the microscope
reveals defectively developed and, according to some observers,
hypertrophied nerve-cells in the cortex cerebri, as well as per-
sistent subcortical nerve-cells, which occur normally in infancy
and are also to be found in the brains of idiots. |
Focal lesions of all parts of the cortex cerebri, basal ganglia and
cerebellum are to be found in many cases of epilepsy and might
‘reasonably be regarded as the primary cause of the disease; but in
the majority of cases no such lesion is to be found. Sclerosis and
atrophy of the cornu Ammonis occur in about 50 per cent. of the
cases. This change, however, together with a general thickening
of the meninges, infiltration of the perivascular spaces with
leucocytes, increase of neuroglial cells and fibres, chromatolysis
with vacuolation of the cortical nerve-cells, degeneration and dis-
placement of nuclei and disappearance or shortening of the
protoplasmic processes, is regarded by most pathologists as the
result, not the cause, of the disease.
The change described by Bevan Lewis as occurring mostly 1n
the small cells of the second layer merits special consideration.
Specimens stained by his “‘ fresh method ’”’ show an unstained
bright refractile droplet of oil in the centre of the nucleus of these
cells. In more advanced stages of degeneration the droplet is
larger and replaces the nucleus. Later on the droplet is dis-
charged and the cell, which still retains its contour, is left in a
vacuolated condition. The change described is not peculiar to
epilepsy, but Dr. Lewis claims that it is never so marked in
other forms of insanity.
Dr. John Turner (formerly of Brentwood Asylum) demonstrated
in the cortical vessels the presence of blood-clots which stain green
with Macallum’s phenyl-hydrazin reagent, showing that they
contain phosphorus and are therefore of ante-mortem origin.
Dr. Turner found this intravascular clotting in go per cent. of
epileptic brains and in only 35 per cent. of control brains. He
also points out that the blood platelets are excessively numerous
in epileptics.
Special attention has been paid by many investigators to
the blood and urine of epileptics, with a view to discovering
abnormal constituents. The general results of these investiga-
tions are—(1) that, during an interval between attacks, the
toxicities of the blood and urine are the same as in the case
PATHOLOGY OF EPILEPSY 365
of a healthy person; (2) that, before a series of fits, the
toxicity of the urine is diminished and that of the blood in-
creased; (3) that, during a series of fits or during an epileptic
psychosis, the toxicity of the urine is still subnormal but tends
to rise, while that of the blood, having been gradually rising
for some time, now reaches its maximum and (4) that imme-
diately after an attack the toxicity of the urine is increased,
while that of the blood is diminished. Krainsky states that the
chief abnormal constituent to be discovered in the blood is
ammonium carbamate and he has succeeded in producing fits in
animals by injecting defibrinated blood drawn from an epileptic
during the course of a paroxysm. The obvious conclusion from
these results per se is that the epileptic crises are entirely de-
pendent on some toxin or toxins circulating in the blood-stream
and that the fit fulfils the function, in some way or other, of
transferring these toxins from the blood to the urine and of
thus getting rid of them. Some authors contend that the bene-
ficial effect of purgatives in diminishing the number of fits
indicates that the gastro-intestinal canal is responsible for the
manufacture of the toxins. The more probable explanation is
that purgatives remove a source of peripheral irritation or
gratify some unconscious desire. It is further stated that the
urine of epileptics contains a smaller quantity of chlorides, phos-
phates and nitrogenous products than that of normal individuals.
Cotton, Corson White and Stedman discovered that the Abder-
halden reaction of the blood of epileptics is always positive to
adrenal tissue or rather, to be accurate, in every one of the
69 cases in which they examined the reaction.
A satisfactory explanation of the phenomena of epilepsy has
therefore many clinical and pathological requirements to satisfy.
It must take account of the facts that epilepsy is associated
by heredity with other mental disorders, that it occurs in subjects
with teratological anomalies of the cerebral cortex, that coma
and other psychical phenomena are associated with the convul-
sions, that the convulsions tend to recur, that each fit is an exact
replica of previous fits in the same patient, that the patient is,
at least in the earlier stages of the disease, perfectly well between
the fits and that the occurrence of a fit usually tends, so to speak,
o “clear the air’’. It commonly happens that a patient who has
been for some days morose, irritable, querulous and suffering
from occasional attacks of petit mal, suddenly has a severe con-
vulsion, followed by sleep for half an hour or so, and is perfectly
well until the preparoxysmal period of his next fit. The explana-
366 MIND AND ITS DISORDERS
tion which we seek must further take account of the occasional
cessation of the pulse during the tonic stage of the convulsion and
of such pathological findings as widespread degeneration of the
cortex, intravascular clotting, sclerosis of the cornu Ammonis,
the recurrent formation of toxins in the blood and their almost
immediate elimination in the urine on the occurrence of a con-
vulsion. We may leave out of consideration the cases in which |
there is a definite irritative lesion of the brain.
The problem which faces us is no easy one and the attempt
to solve it has given rise to numerous theories as to the nature
of epilepsy. The most important are: (1) The theory of cortical
instability, (2) the vasomotor theory, (3) the toxin theory and
(4) the theory of intravascular coagulation.
The theory of cortical instability regards the epileptic as a
person whose cortical neurons are so irritable that they occa-
sionally burst into explosive activity from any trifling stimulus,
peripheral or central, and give rise to a convulsion. This theory
fails to explain the fact that an unstable cortex occasions
epilepsy in one person and maniacal symptoms in another, but
it is justified in that it recognizes the cerebral cortex to be the
seat of the disorder, a fact which is at least minimized, if not
totally ignored, by the supporters of the toxin theory. That the
physical basis of epilepsy lies in the cortex cerebri is obvious
from the study of the family histories of epileptics, from the
cortical deformities and from the frequent association of mental
disturbance with convulsions. The theory fails, however, by
being incomplete. It throws no light on the nature of the
changes in the blood and urine.
The vasomotor theory takes account of the fact that convulsions
are readily caused by the cortex being suddenly deprived of
its normal vascular supply, either by cerebral embolism, ligature
of the carotids or severe anemia from loss of blood. It further
takes account of the occasional cessation of the pulse during the
tonic stage of a fit, regarding such cessation as a vago-cardiac
inhibition to check a continuous rise of blood-pressure induced
by a widespread area of vaso-constriction. The view that such
vaso-constriction occurs is supported by the observation that
inhalation of amyl nitrite is sometimes successful in arresting
an attack. One of my patients, who came to me with a history
of one fit every day, and also suffered from Raynaud’s disease,
had her fits entirely arrested by the administration of Io minims
of the tincture of belladonna three times a day. According to
the vasomotor theory, epileptic convulsions are caused either by
THEORIES OF EPILEPSY 367
the blood-supply to the cortex being cut off by a local vaso-
constriction or by a sudden fall of blood-pressure following a
rise caused by a widespread vaso-constriction. The Raynaud’s
disease cases belong to the former class and the cases accom-
panied by cessation of the pulse to the latter.
According to the toxin theory, the fits are due to periodic ac-
cumulation of fit-producing substances in the blood, especially
ammonium carbamate. In accordance with this theory the
direct effect of a convulsion is to cause the sudden elimination
of toxins from the blood into the urine; otherwise there seems
to be no reason why the convulsion should cease in so short a
time. In this connection the reader will do well to recall the
mental symptoms of toxemia, viz., hallucinations, anesthesia
and mental confusion, all of which occur in association with
epileptic fits.
The theory of intravascular coagulation claims that the con-
vulsions are directly due to cutting off the vascular supply to
the cortex by the formation of blood-clots within the cortical
vessels. That such coagulation occurs Dr. Turner has con-
clusively demonstrated and he explains the fact that every
fit occurring in any given patient is almost an exact replica of
previous ones on the supposition that the character of the fit is
determined by the position in the cortex of the imperfectly
developed nerve-cells. Dr. Turner correlates the fact that the
cornu Ammonis is especially liable to sclerosis and atrophy with
the observation that the injection of clove oil into the jugular
vein of a rabbit is especially apt to cause hemorrhages in the
same region of the cerebrum.
There seems to be no reason why we should discredit any of
these theories. Our view of the pathogenesis of epilepsy will
therefore be arrived at by an attempt to reconcile them some-
what after this fashion. The disease occurs in persons with an
imperfectly developed cortex cerebri. Owing to the accumula-
tion of toxic products in the blood the vascular supply to the
cortex is cut off by intravascular clotting and arterial spasm,
these conditions giving rise to convulsion. The direct result of
such convulsion is to eliminate the toxins from the blood and to
cause the patient to return to his normal health. The instability
of the cortex and the formation of toxins can hardly be a hap-
hazard combination of circumstances. We therefore seem to
be driven irresistibly to the conclusion that such toxins are
manufactured within the nervous system itself.
. But all this takes no account of the essential mental peculiari-
368 MIND AND ITS DISORDERS
ties of the epileptic, his affective immaturity, especially in the
psycho-sexual sphere, the psychical meaning of the fits or their
equivalents as libidinous outlets or strivings of the unconscious
and the fact that they are as much the fulfilment of unconscious
wishes as dreams are. What the exact relationship is between
the mental and physical characteristics of the epileptic and
which of these is responsible for the other are problems which
still remain unanswered.
For example, the reason why the Abderhalden reaction of the
blood of epileptics is positive to adrenal tissue has not yet been
explained. Perhaps it is to be correlated with Cannon’s dis-
covery that every emotion is accompanied by an increase (or
diminution) of the amount of adrenalin in the blood. This
notion would, at any rate, not militate against the results of
psycho-analytic investigation.
The reader will rightly conclude from this section that the
pathology of epilepsy is still obscure; but I am sure that he will
be wise in laying due weight upon the mental aspects of this
disease.
Treatment.—When the physician is confronted with a case
of epilepsy, it is his first duty to subject the patient to a most
searching physical examination in order to ascertain whether
there are, on the one hand, any peripheral sources of irritation,
such as eye-strain, an uncompensated heart, indigestion and
constipation or, on the other hand, any irritative lesions of the
central nervous system which are capable of being localized.
Eye-strain should be treated with suitable spectacles; heart
disease, indigestion, constipation and similar disorders on general
medical principles. Localized cerebral lesions should be first
treated with hexamine and acid sodium phosphate in case they
should be of infective or syphilitic origin. If such treatment
fail to ameliorate the condition it may be desirable to resort to
surgical measures.
The patient should lead a regular life, keep early hours and
live on a plain, nutritious, fattening diet, avoiding excess of
nitrogenous food and totally abstaining from alcohol in any
form. Under this régime it often happens that the fits entirely
disappear. When I was resident at the National Hospital in
Queen Square it was by no means an uncommon occurrence
for an epileptic who had been treated as an out-patient on
potassium bromide, to be admitted with a history of one fit every
day in spite of treatment. On admission bromide was with-
held until a fit had been seen and described; the simple life
TREATMENT OF EPILEPSY 369
proved to be so beneficial that not a single fit occurred during
a month’s residence in hospital.
Under this régime a record of the fits should be kept and their
frequency noted; three fits a day, one a week or one a month
as the case may be, unless the doctor is adopting some form of
psychotherapy under colony conditions. The patient is now
placed on bromide treatment, say 10 grains of sodium bromide
night and morning and the frequency of the fits again noted.
If they are entirely arrested the treatment can be continued for a
few years and the dose then gradually reduced; if not, the dose
should be increased and the frequency of the fits again noted. In
this way the dose should be gradually increased up to the point
beyond which no further diminution of the fits is accomplished.
As a general rule it is not advisable to go beyond 45 grains of
sodium bromide in the course of the day. A bromide rash may
be avoided by the addition of 2 or 3 minims of liquor arsenicalis
to each dose of medicine. It is usually desirable to add a mild
saline aperient, say 15 to 20 grains of magnesium sulphate in each
dose. A latter-day drug that is sometimes used instead of sodium
bromide is luminal-sodium. In any but very small doses it has
a stupefying or staggering effect on the patient; I therefore prefer
to add quarter-grain doses (never more than half-a-grain) to the
bromide mixture. Dialacetin is another drug to which the same
remarks apply.
If convulsions still persist various adjuvants may now be added
to the mixture, borax being the first, beginning with doses
of 5 grains and working up to Io or even 20 grains should it
be successful in diminishing the frequency of the convulsions.
The maximum dose of the drug is that beyond which no appre-
ciable benefit is obtained.
Now try lactate of zinc, tinctures of digitalis, belladonna
and hyoscyamus, chloral hydrate and the liquor morphine
bimeconatis, always keeping a record of the fits and noting the
effect on the patient of the addition of any particular drug.
If the drug proves beneficial it should be continued, if useless
dropped. Above all things rule-of-thumb methods are to be
avoided in the treatment of epilepsy; in no condition is it more
important for the physician to bear in mind the rule that he
should treat the patient and not the disease.
Patients suffering from thirty or forty fits a day require more
immediate and urgent treatment. In such cases the bromides
are not very efficacious; chloral hydrate has proved a more
useful drug. The best mode of administration is to give re-
24
370 MIND AND ITS DISORDERS
peated doses in sufficient quantity, usually 10 to 15 grains
three times a day, to keep the patient asleep, except for meals,
for several days, perhaps for a fortnight in severe cases. The
bromides may then by degrees be substituted for the chloral
hydrate. | :
Status epilepticus should be treated by giving a hypodermic
injection of morphia, about 4 grain, and repeating it in three
hours if necessary. A useful adjunct is an enema containing
ro to 12 grains of chloral hydrate, after clearing the rectum as
much as possible with a soap-and-water enema. Occasionally
it is necessary to resort to chloroform inhalation.
For those patients who have a definite warning before their
fits the inhalation of amyl nitrite is sometimes successful in .
preventing an actual convulsion. If the warning consists of
a sensation in one of the limbs the convulsion may occasionally
be warded off by giving a strong sensory stimulus to the limb
by tying tightly round it a ligature such as a handkerchief.
Epileptics should be under constant observation for the pre-
vention of such accidents as falling into the fire, drowning in
the bath or suffocation by the bedclothes when a fit occurs
during sleep. The part of the body on which the patient usually
falls should be covered with a pad. In some institutions pillows
of reeds instead of flock are used for the purpose of minimizing
the risk of suffocation, should a fit occur while the patient is
in bed.
All that has been said with regard to treatment applies equally
to sane and insane epileptics.
On the other hand, it must not be forgotten that one purpose of
the epileptic convulsion is to eliminate toxins from the system
and the question therefore arises whether it is not advisable
to let some epileptics have their fits. Bromide undoubtedly
does good in most cases, but it is not known in what way it acts—
whether, for example, it neutralizes the toxins chemically or acts
as a sexual sedative physiologically. We ought really to know
this much before deciding whether it is desirable or not to give
bromide at all. Indeed I have heard a very thoughtful and
observant physician express a doubt whether bromide is of any
use in the treatment of epilepsy.
Every effort should be made to wean the patient from his
infantile unconscious desire for dependence on his mother or
father or their surrogates, such as the nurse or doctor. He
should be removed from his own home and placed in a colony
where, on the one hand, he is encouraged to lead his own life
PSYCHOGENETIC EPILEPSY sya
and, on the other, he is protected from irritations, as much as
possible, which might induce him to regress into an infantile
attitude of dependence. He should not be drilled into possibly
uncongenial work in company with others, but allowed to find
his own interests. The doctor may deem it desirable tactfully
to instruct the patient that he can cure himself in this way.
An open-air life is best, with plenty of opportunity for occupa-
tion, exercise and games, into which he may sublimate his libido.
The diet should be non-stimulating sexually, alcohol must there-
fore be excluded and the allowance of meat restricted. From
psycho-analytical considerations I would especially restrict pork,
ham and bacon. Beef is undesirable for physical reasons.
Lastly the patient should be psycho-analyzed if there is
any possibility that his fits may be of hysterical origin (“ psycho-
genetic epilepsy’’). Some hysterical fits present exactly the
same features as true epileptic ones.
These are ideal conditions impossible for the enormous number
of epileptics in this country. The present position is that several
epileptic colonies are in existence but that, for financial and
other reasons, they are not equipped and staffed in such a way
as to provide this ideal treatment. We can only hope that the
recognition that epilepsy is a curable disease may induce some
of our charitably inclined millionaires to place suitable epileptic
colonies on a sure footing or—better—prompt our money-
spending authorities to divert some of their useless expenditure
into soul-saving channels.
CHAPTER AIT:
ALCOHOLISM,
WE have seen that both epilepsy and dementia pracox are
psychoses whose function is to aid their victims to fulfil a desire
to retreat from the world of reality in one way or another.
Some people achieve the same end by taking excessive quantities
of alcohol or drugs, especially those which induce sleep or, short
of this, benumb consciousness to such an extent that it permits
the unconscious to fulfil its wishes, either in phantasy or in such
activities as would not be tolerated by these people under
normal conditions.
As a paradigm let us consider alcohol. The inclination to
drink too much can usually be ascribed to conviviality or re-
peated attempts to drown some sorrow. In both these circum-
stances the alcoholic drinks enough to let his unconscious have
its fling and thus finds happiness; but inasmuch as conviviality
and profound grief do not invariably lead to alcoholic excess or
even mental abnormality of any other kind, there must be
some deeper-lying cause. This has been revealed by psycho-
analytic investigation of such patients; for it is found that all
alcoholics and drug-takers have a large homosexual complex.
Homosexuality is an intolerable idea, conflicts with conscious
trends of thought and is therefore repressed. Whenever it
subsequently escapes the repression it is bound to give rise to
intrapsychic conflict. This is too much for the individual to
bear and he therefore seeks comfort in alcohol, morphia or some
other drug. The manner in which these achieve their object
varies from patient to patient, and it can only be revealed by
psycho-analysis.
It is not to be understood from the above remarks that every-
body who takes a glass of wine with his meals or likes a tot of
whisky at night is a repressed homosexual. They refer only to
those people who feel a need for alcohol, those—for example—
who imbibe enormous quantities towards “ closing-time’’ to
tide them over the “ dry ”’ period. During the War such persons
suffered so much from the restrictions of the Liquor Control
372
‘ALCOHOLISM 373
Board that many experienced an attack of delirium tremens
for the first time as a direct result of those restrictions.
Whether alcohol is imbibed in small or large doses, the aims
and results are the same. In small doses it temporarily
obliterates from the memory the many little worries of life and
therefore serves the useful purpose of helping man to adapt
himself to his environment. When he drinks large quantities,
our conclusion must be that he has much more troublesome
and serious conflicts to face, or efface, than the majority of his
fellows. In neither case is the individual fully aware of the
nature of the wish he is fulfilling (the conflict he is solving) by
drinking alcohol and therefore the reason why he takes it is
unknown to him—it is unconscious. But all know that alcohol
brings peace of mind and this psychological activity of the drug
must never be forgotten by those who have to minister to patients
suffering from physical diseases, either in hospital or in private
practice.
Not every case of mental disease with a history of previous
alcoholic excess is caused by alcohol. Many attacks of insanity
are ushered in by an alcoholic bout, this being a symptom and
not a cause of the disorder. Again there are cases of mental
disease not to be classed as intoxication insanities, although
they owe their origin to degeneration of the nervous system
induced by alcoholic excesses. Of this nature are some cases of
epileptic insanity and intermittent insanity (mania and melan-
cholia). Alcohol also plays an important réle in the causation
of some cases of arterio-sclerotic insanity, senile dementia and
perhaps general paralysis.
TREATMENT OF ALCOHOLISM.
The question naturally arises whether alcoholism can be
either prevented or cured.
Prevention could best be achieved by education. By this I
do not mean useless lectures on the evils of ‘alcohol, but the
training of children in such a way that they will not feel the need
of alcohol or any substitute for it when they grow up. This is
admittedly a very great problem requiring, among other factors,
a similar education of the parents during their earliest years.
It ought not to be necessary that every individual of an ideal
community should be a total abstainer in order to avoid being an
alcoholic.
Another suggested method is the total abolition of alcoholic
374 MIND AND ITS DISORDERS
beverages, so that they are unprocurable. The United States
of America have already adopted this expedient. The experi-
ment should prove interesting; for it seems to the writer that
those people, whose mental conflicts are such as would cause
them to seek relief in alcohol, must either turn to some worse
drug or solve their conflict through psychosis. I understand
that the truth of this dictum is manifesting itself in America
even earlier than I had expected. When war conditions in this —
country necessitated the requisitioning of distilleries and breweries
as munition factories the Board of Liquor Control acted wisely
in the author’s opinion by limiting the output of alcohol without
abolishing it; but prolongation of even limited restrictions
would presumably lead to some form of mass paranoia. Indeed
there is still a mysterious “industrial unrest”, and it is
probable that total prohibition in Russia played an important
role in the production of the present state of anarchy in that
great country.
The psychological mechanism is interesting. Should revolu-
tion break out, the people would never admit, even to them-
selves individually, that their actions were due to the inaccessi-
bility of or repressed desire for alcohol; such an idea would be at
once repressed and find an outlet in some form of mass psychosis
(revolution, for example). Any Government or body of men
seeking to toy with the habits of a nation should avail them-
selves of the services of a practical psychologist before putting
their ideas into execution.
The cure of alcoholism is only possible when the patient
himself is anxious to be cured and is prepared to co-operate in
the process.
There are a few medicines which have a reputation for diminish-
ing or abolishing the desire for alcohol, such as sodium bromide
in large doses (20 grains three times a day), strychnine, apomor-
phine hypodermically and tincture of capsicum by the mouth.
In mild cases they are undoubtedly helpful, but in more severe
cases we have to resort to psychotherapy.
In a few very rare cases the patient succeeds in relinquishing
his habit without any outside aid, his self-respect serving as a
sufficiently strong motive. As a rule, however, he requires
assistance which can be given in one of two forms: psycho-
analysis or suggestion. The first teaches the patient to under-
stand himself and is therefore fundamental; but unfortunately
it takes a very long time (daily for at least six months). The
second, which is given cither in the sleeping or waking state,
ALCOHOLISM 375
has the disadvantage that it makes the patient permanently
dependent on the physician. The hypnotic treatment is given
daily for a week or two, then on alternate days, then twice
a week, once a fortnight and so on to once in six months.
Whichever method is adopted, however, we find that many
patients discontinue it too soon and consequently relapse. No
treatment is successful without the patient’s cordial co-operation
toa finish. |
A curious latter-day treatment is the production of a delirious
state for several days by maximal doses of hyoscine; I have no
experience of the method.
GHAPIER SAI:
SOME OTHER DRUG HABITS.
THESE are psychoses whose psychopathology and general treat-
ment are the same as those of alcoholism as described in the
previous chapter.
MoRrPHINISM.
Etiology.—The abuse of opium and its alkaloid morphia is less
frequent than alcoholism because these drugs are more expensive
and less easy of access to the general public than alcohol.
Accordingly we find morphinism most frequently among medical
students and practitioners, dentists and nurses, who have experi-
ence of the drug and little difficulty in obtaining it, and among
the wealthier classes to whom expense is no obstacle.
Begun in the first instance for the relief of insomnia or some
frequently recurring pain, the morphia habit may become
confirmed in less than six weeks, so that the patient is not only
unable to discontinue the use of the drug but is obliged to resort
to it in ever-increasing doses. In a few patients the habit is
started by a single dose taken either to see what the sensation
of morphia intoxication is like or to stimulate cerebral activity
for the purpose of getting through an increased amount of
mental work. More than three-fourths of the patients are men
and the habit is usually contracted in the third or fourth decade
of life.
In its physiological action morphia diminishes all secretions
except the sweat and it is a motor sedative. The drug has
therefore a pronounced action upon the functions of the ali-
mentary canal; it causes dryness of the mouth, disturbs the
digestion, diminishes the appetite for food and induces con-
stipation. The pulse-frequency is diminished and the blood-
pressure lowered by dilatation of the peripheral arterioles. The
dilatation of cutaneous vessels causes a feeling of warmth.
The respiration becomes shallow and the bronchial secretion is
diminished. The pupils are strongly contracted.
In its specific action upon the nervous system morphia is a
local anesthetic and anodyne. By its action on the cerebral
370
ABSTINENCE FROM MORPHIA ST
cortex it produces a peaceful feeling of happiness and comfort
and it stimulates the imagination, in this way increasing the
capacity for mental work. In the later stages of its action, if
taken in sufficient quantities, it promotes sleep.
When taken habitually, the organism acquires an increasing
tolerance for the drug so that the administration of larger and
larger doses becomes necessary to procure the above results.
It may be presumed that this tolerance results from the forma-
tion by the tissues of protective substances antagonistic to the
action of morphia. If Marme’s statement be correct that the
antagonistic substance is oxy-di-morphine, we may conclude
that the antagonistic action of the organism consists in an attempt
to oxidize the morphia introduced into the system.
Abstinence Symptoms.—Whatever the above natural antidote
to morphia may be, it must be held responsible for the symptoms
which arise when a morphinomaniac is suddenly deprived of his
usual dose.
The symptoms are those of poisoning by a perfect antidote
to morphia. There is increase of all the secretions of the body
except the sweat and there is general hyperesthesia of the skin
- and mucous membranes. Consequently vomiting and diarrhoea
with tenesmus are prominent symptoms and many patients can
retain only liquid food. There is also a slight “‘ cold in the head ”
with troublesome sneezing, salivation and slight cough. Uncon-
trollable yawning and hiccough also occur.
. The pulse-frequency is increased and the blood-pressure raised
by contraction of the peripheral arterioles. On account of the
contraction of the cutaneous vessels, the patient feels cold and
asks for extra blankets. Some patients complain of feeling cold
internally. Palpitation and syncope are liable to occur, the
latter being one of the gravest symptoms which the physician
has to combat in the treatment of these patients.
There is hypereesthesia of all the senses; the patients complain
that the light is too strong and that there is too much noise
going on around them. Some suffer from neuralgic pains and
other unpleasant sensations in various parts of the body; lights
appear before the eyes and there is singing in the ears.
Muscular debility and a sense of fatigue set in, so severe in
some cases that the patient is scarcely able to stand. If he be
asked to extend his fingers, they are seen to be tremulous.
Muscular twitchings and cramps occur in the limbs; even general
convulsions are reported by some observers. General motor
restlessness is a constant symptom which, in some patients,
378 MIND.AND ITS DISORDERS
attains the severity of true maniacal excitement for a short
period, perhaps with suicidal or homicidal impulses. The super-
ficial and tendon reflexes are greatly exaggerated.
The emotional attitude of the patient is one of abject misery;
and it is this mental depression associated with absolute insomnia,
more than any other symptom, which induces patients to abandon
the attempt to get rid of the morphia habit, knowing as they
do that a single injection of the alkaloid will alleviate all their
troubles.
Morphia habitués are unreliable, incapable of persistent appli-
cation to work, untruthful, depraved, immoral and lable to
excesses of debauchery. After many years, insanity (usually
melancholia) may be the result of chronic intoxication by
morphia.
Often and again does the morphinomaniac determine to end
his ways and give up his habit, but the alkaloid and the syringe
are at hand and the temptation invariably proves too strong.
He may make a determined effort, pour his stock of morphia
down the sink and break his syringe; but he finds he has to
contend with more than the force of habit. Abstinence symp-
toms arise and become intolerable. A new syringe and stock of
morphia have to be purchased and the patient learns that he is
a slave to the drug, body and soul.
Diagnosis.—The diagnosis of morphinism rarely presents any
difficulty. The patient usually comes under observation with.
a definite history of the habit and with the request to be cured.
Moreover, the alkaloid may be detected in the urine and there
are commonly to be found many scars of old abscesses caused
by the use of a dirty hypodermic syringe. Should any
doubt arise, the diagnosis is easily cleared up by placing
the patient in circumstances in which he can have no
possible access to the drug. Abstinence symptoms are sure to
appear within twenty-four hours if the patient is addicted to
morphia.
Prognosis.—It is said that the morphia habit does not tend
to shorten life. On the other hand, the possibility of a complete
cure without subsequent relapse is small (10 per cent. of the cases,
according to Kraepelin). The outlook is better for those patients
who have been accustomed to take their morphia in the form of
opium than for those who take the pure alkaloid, better for
those who take it by the mouth than for those who take it
hypodermically and better for those who take morphia alone
than for those who take other drugs with it.
TREATMENT OF MORPHINISM 379
Treatment.—It is advisable at the outset to warn the patient
that he must be prepared to endure a considerable amount of
suffering while he is being cured, at the same time assuring him
that every effort will be made to mitigate his symptoms. He
should also be told how long the acute stage of his illness will
last, about five days if morphia is completely withheld from
the first. By thus dispelling all doubt, one important source of
restlessness is removed.
The patient is then put to bed and carefully examined in
order to ascertain, inter alia, that he has no morphia secreted
about him. The room should be quiet, warm and well ven-
tilated and the bed should not face the window, which ought to
be supplied with a blind.
The diet is nourishing and consists mainly of liquids (milk and
broths) so as to avoid gastro-intestinal irritation and to promote
urinary secretion.
The weaning of the patient may be accomplished slowly,
rapidly or abruptly. With the slow method the dose is daily
reduced by about one-tenth. Thus, a patient whose habitual
dose had been 30 grains daily would during treatment receive on
mieesivedaye 27, 24,22)20;18,'16, 14, 12; Ir, 10,9, 8, 7, 6,75;
4k, 3, 24, 2, 14, 1, 2, 4, 4 grains, the drug being then discontinued.
In the rapid method the dose is at first reduced by nearly one-half
daily. Erlenmeyer gives the following table:
RAPID METHOD OF WEANING.
Habitual Dose | e10=3004 30-40.) -40-50,.} O+50-i, |, - 1-2;
i Ce g. Cg Gr Gr.
First day et 8 I5 | 25 30 cg 50 cg
Second _,, ~ 2 | 6 $2) Pabe1 5) 8 20 30
Third _,, biel we 10?) Mh 12's 4) PS 20
Fourth ,, 3 6 Fo ste 12 15
Fifth % 2 4 4 8 | 10
Sixth ig I 3 x 6 | 6
Seventh ,, — 2 2 4 bss
Eighth _,, — I I 2 2
Ninth ,, oa — — I I
In the abrupt method no morphia is allowed from the moment
when treatment is commenced, unless syncope or some other
form of collapse threatens, when one or two injections of $ grain
each are administered in order to tide the patient over the
danger. To the author this method appears to be the least
objectionable unless the previous dosage has been more than
380 MIND AND ITS DISORDERS
10 grains a day; because, although the illness is more severe, it
is less trying to the patience of the sufferer. Whichever method
is used a hot bath greatly conduces to the comfort of the patient
and should be given night and morning.
Further to alleviate the patient’s sufferings during this trying
time certain drugs have been recommended as temporary sub-
stitutes for morphia, viz., alcohol, chloral and especially cocaine.
Cocaine has been greatly praised by Berkley and Obersteiner.
If used, the dose should never exceed 10 grains daily, it should
be given by the mouth and the patient should on no account
be allowed to learn the nature of his medicine. The morphino-
maniac is usually well acquainted with the literature of his
disease and, all too often, he attempts to cure himself by taking
to cocaine. The remedy is worse than the disease, for the
invariable result is that he becomes a slave to two drugs instead
of one. More recently meco-narceine (Duquesnel’s solution)
and combretum sundaicum have been recommended in the
substitution treatment of morphinism. The latter drug has
been used as a cure for the habit in the East; 17 minims of the
liquid extract three times a day corresponds to the dose taken
by the natives. I have tried it on patients without being
impressed by the property ascribed to it; but I am rather averse
from substitution treatment of any kind. It is too lable to
give the patient a superadded drug-habit.
Insomnia should be combated by a different hypnotic e every
night, the changes being rung on paraldehyde, amylene hydrate,
dial, sulphonal, trional and chloral hydrate. Bicarbonate of
soda is an invaluable remedy for the relief of gastric hypersecre-
tion and hyperacidity and should be given as a routine medicine.
Erythrol tetranitrate may be given in }-grain doses to lower the
pulse tension if necessary, and digitalis is useful to restore a
failing heart. When the circulation is in danger, however, and
collapse threatens, the author is in the habit of resorting to
morphia. Here, as in the case of alcohol, the safest and most
certain remedy for the patient is “‘a hair of the dog that
bit him ”’.
During treatment the patients lose much weight, which is
more than regained during convalescence as they gradually
return to a normal diet. Convalescence should be prolonged to
three or four months at least in order to allow time for restoring
the nervous system and to establish the habit of doing without
the drug.
In the meantime some form of psychotherapy should be
DRUG HABITS — 381
initiated. The only gratifying results are obtained from a
complete psycho-analysis which invariably reveals the patient
to be fixated at the auto-erotic-homosexual level.
COCAINISM.
Etiology.—The cocaine habit arises in much the same way as
the morphia habit, but it has an additional etiological factor
in that morphinism predisposes to it. Morphinomaniacs take
to cocaine either as an adjuvant or as a substitute for morphia
or as a local anesthetic prior to an injection of morphia. I have
been struck by the large number of cases of cocainism started
by an attempt to relieve the discomfort associated with diseases
of the nose.
The physiological effects of cocaine are largely induced by its
stimulating action on the sympathetic system. It raises the
blood-pressure by contracting the peripheral arterioles and in-
creasing the frequency of the pulse. In the same way it dilates
the pupils, causes retraction of the eyelids and induces proptosis
by the stimulating effect upon Miiller’s muscle. Glandular
activity is increased throughout the organism. Locally applied
it causes anesthesia of the part by cutting off the blood-supply
from the peripheral nerve-ends.
In its action on the cerebral cortex cocaine reduces fatigue
and causes motor restlessness and excitement. It drives away
care and induces a pleasant feeling of peace and well-being. It
appears to have a special action on the writing centre, for cocaine
habitués write interminable letters which may be abnormally
brilliant just after an injection. Association of ideas is facili-
tated and memory and judgment are improved. The drug
destroys the appetite for food. One patient, addicted to cocaine
alone, told me that it destroyed the desire for sweet articles of
diet, whereas he had a craving for sweets when he was deprived
of the drug; medical psychologists will appreciate the deeper
meaning of this symptom. Large doses cause muscular spasms
especially of the face.
Cocainism is almost invariably associated with morphinism,
addiction to cocaine alone being rare. It is remarkable that,
although sudden abstinence from cocaine causes much less dis-
tressing symptoms than abstinence from morphia, the former
is much more difficult to renounce and the proportion of relapses
after apparent recovery is greater.
The abstinence symptoms are dryness of the mouth, apepsia
and constipation, muscular weakness with tremor, especially of
382 MIND AND ITS DISORDERS
the tongue, diminution of the pulse-rate with fall of blood-
pressure and a tendency to syncope.
Some patients complain of pains in the limbs, mostly in the
neighbourhood of joints; but most characteristic is formication
of the hands, a sensation of small worms or ants crawling under
the skin. Black specks, which may also be mistaken for small
insects, float before the eyes and there may be hallucination of
hearing. |
The association of ideas is uncontrolled, volition is weak and
the memory for recent events, even for weeks back, defective.
In conjunction with a general feeling of depression the judgment
is warped, so that the patients get the idea that the hand of
every man is against them; they become anxious and fear all
manner of impending harm. Especially are wives distrusted
and accused of infidelity (‘‘ cocaine paranoia’’). The patients
are often impulsive and violent; they may wilfully destroy
valuable property by reason of some fantastic delusion; they
may murderously attack their supposed persecutors or commit
suicide in order to escape them.
The abstinence symptoms appear to be, as with morphia, due
to intoxication by a perfect antidote to cocaine, formed by
the tissues—it is reasonable to suppose—in their attempts to
counteract the evil effects of the drug.
The usual clinical picture of the cocaine habitué presents the
above symptoms of cocaine poisoning and cocaine abstinence in
a confused mass, sometimes one symptom, sometimes another
becoming the more prominent according to the recency and
magnitude of the last dose.
Diagnosis.—The history of cocainism is seldom wanting. In
its absence the diagnosis may be difficult, but the same principles
are to be applied as in the diagnosis of morphinism. Formica-
tion of the hands is more than suggestive. Cocaine paranoia is
to be distinguished from alcoholic paranoia by the greater
rapidity of its onset and course.
Prognosis.—Temporary recovery from cocainism usually takes
place after a few months of enforced abstinence, the acute
symptoms passing off within the first few weeks. The drug is,
however, so enslaving that relapse occurs even more frequently
than with morphia. Cocaine paranoia is liable to last several
months and a few patients become permanently insane.
Treatment.—The same principles of weaning the patient apply
as in the case of morphia, but there is less danger of collapse
during treatment. The same hypnotics may be used and nux
DRUG HABITS 383
vomica with hydrochloric acid may be given as a routine medicine.
Similarly, psychotherapy is almost invariably required to com-
plete the cure.
CHLORALISM.
In these days of insomnia it is not surprising to find that the
drugs which the average man finds most alluring are the hypno-
tics. Morphia has the greatest number of adherents. A few take
to chloral (usually women), paraldehyde, sulphonal and others.
When a person habitually uses chloral his organism gradually
becomes inured to the usual dose, which then proves insufficient
- to produce the normal physiological effect, presumably on
account of an increased formation of antibodies of some kind
or other by the tissues.
If at this stage the patient is prepared to put up with several
sleepless nights he may be able to throw off the chloral habit;
but this is too much to expect from human nature. Increasingly
larger doses are taken at first nightly, then during the day as
well, until a definite attack of insanity supervenes. This is
apparently due, not directly to chloral, but to the above-
mentioned antibodies; for the phenomena are precisely the
same as those which arise when the habitual ingestion of chloral
is abruptly suppressed.
Symptoms.—Mental disorder arising from the chloral habit
occurs in one of three forms:
1. Motor excitement and agitation with hallucinations of
vision and hearing, especially in the evening, and sometimes
with epileptiform attacks.
2. Depression with heaviness, torpor and muscular weakness,
which may also be complicated by hallucinations; and
3. Delirium tremens which, in the absence of a history, can
only be differentiated from alcoholic delirium tremens by the
odour of chloroform in the breath.
Insomnia occurs in all three forms. Some patients complain
of irritation of the skin, pains in the joints and dyspepsia.
Prognosis. Recovery occurs after prolonged abstinence.
The literature of the subject is too meagre to allow of our deter-
mining whether there is much tendency to relapse. Besides,
chloral has rather fallen into popular disrepute among the multi-
tude of latter-day hypnotics.
Treatment.—It is said that the patients are liable to syncope
and that the abrupt method of weaning is therefore inadmissible ;
but, if the patient appears to be in fairly good general health,
384 MIND AND ITS DISORDERS
the rapid method mentioned in the account of the treatment of
morphinism may be employed; if not, the physician should
resort to the slow method.
PARALDEHYDISM.
I have met with a few instances of intemperate addiction to
paraldehyde, two of which came under my observation as certi-
fied cases of mental disease. |
The patients suffer from great motor excitement with occa-
sional violence, tremor of the lips and tongue with disturbance
of articulation and fibrillary tremor of the muscles of the chest.
Some exhibit tremor of the fingers. There is marked impercep-
tion with loss of memory and the patient may be unable to
recognize his former acquaintances; hallucinations of vision and
hearing occur.
Physically the most striking symptom is a profuse bronchor-
rhoea which may persist for a week or more after the last dose
of paraldehyde.
_ When the excitement subsides the patient falls into a condition
of extreme lassitude which gradually passes off as convalescence
is established.
Prognosis.—All of my patients made a complete recovery,
with the exception of one who remained in a state of mild
dementia. So far as I am aware, none of the cases has relapsed.
Treatment consists of complete suppression of the drug, the
mitigation of symptoms on general medical principles and over-
feeding.
CHRONIC SULPHONAL POISONING.
This condition is occasionally met with. Hamatoporphyrin-
urla is the most common symptom; but sometimes the friends
seek the advice of the medical man because the patient is always
asleep and is supposed to be suffering from “‘ sleeping sickness ”’.
The latter disease is excluded and the physician put on his guard
by the absence of trypanosomes from the blood. The diagnosis
is cleared up by placing the patient in circumstances in which
he can have no possible access to drugs: the sleepy condition
then passes off. Some of the patients have a shuffling or stagger-
ing gait. I had one case of chronic cortical atrophy in a woman
of fifty, apparently caused by taking large doses of sulphonal
every night for sixteen years. The patient passed out of my
hands and I learned that the ultimate issue was fatal.
During* treatment the patient should be kept in bed. No
DRUG HABITS 385
untoward symptoms arise from the abrupt suppression of sul-
phonal. Convalescence is established after a few sleepless nights,
which do no harm.
CANNABIS INDICA POISONING.
Indian hemp is largely taken in the form of haschisch by the
natives of India, Persia, Asia Minor and Egypt for the purpose
of inducing pleasurable motor excitement and hallucinations,
which are commonly sexual in character among Eastern races.
Hallucinations of vision are also common.
The drug also causes epigastric sensations with anzsthesia
of the arms and legs. The time-sense is impaired in such a way
that time appears to pass slowly.
The pulse is frequent and of low tension; the face is pale and
the pupils are dilated, but they react to light.
Acute intoxication by haschisch is characterized by drowsiness
with a pleasant feeling of exaltation and happiness. The sense
of fatigue is abolished. The gait is sometimes staggering, as in
alcoholic intoxication.
Acute delirium sometimes occurs as the result of chronic
haschisch poisoning. This is characterized by hallucinations of
all the senses, accompanied by delusions of persecution or of
exaltation. The patients are restless and sleepless, but not to
the same extent as those suffering from alcoholic delirium.
Dr. Warnock, in the Journal of Mental Science for January,
1903, states that acute mania from haschisch varies “‘ from a
mild short attack of excitement to a prolonged attack of furious
mania, ending in exhaustion or even death’’. The patients
suffer from delusions of persecution or of grandeur. Gustatory
and auditory hallucinations are not uncommon. “A certain
impudent, dare-devil demeanour is a characteristic symptom.’
Chronic delusions of persecution and chronic mania sometimes
occur. If hallucinations are experienced, they play an un-
important role.
Lastly chronic dementia develops with amnesia, apathy,
degraded habits and loss of energy.
Under the name “ cannabinomania’’ Warnock describes the
mental condition of haschisch users between their attacks of
acute insanity. ‘‘ They are good-for-nothing, lazy fellows who
live by begging and stealing, and pester their relations for money
to buy haschisch, often assaulting them when they refuse their
demands. The moral degradation of these cases is their most
salient symptom; loss of social position, shamelessness, addiction
25
386 MIND AND ITS DISORDERS
to lying and theft, and a loose, irregular life, make them a curse
to their families.”’
It is clear that some of these mental disorders are psychotic,
the drug playing but a secondary role. The patient has some
terribly serious mental conflict to solve and he seeks its solution
vid Cannabis indica as well as vid psychosis.
BELLADONNA AND ATROPINE POISONING.
Belladonna and its alkaloid atropine are liable to give rise to
mental symptoms if taken in poisonous doses. In a few patients
with idiosyncrasy for the drug these symptoms may be induced
by so small a dose as that used in atropizing the eye as a pre-
liminary to estimating a refraction.
Excluding criminal cases, poisoning usually occurs either from
eating belladonna berries or from taking a medicine in which the
liniment has been accidentally used instead of the tincture.
The physical signs are dryness of the throat, a scarlatiniform
rash and dilatation of the pupils with paralysis of accommoda-
tion. The pulse is greatly accelerated and fainting may occur.
The characteristic mental symptom is visual hallucination.
This has a special tendency to take the form of threads, hairs,
wires and similar objects. There is busy delirium, the patient
occupying himself by apparently picking threads out of the tips
of his fingers, sewing with needle and thread or plucking fruit
from a tree and eating it. In severe cases complete unconscious-
ness occurs.
The symptoms usually subside in the course of three or four
days, but the memory may be defective for a week or more.
Treatment consists of washing out the stomach and administer-
ing a solution of tannic acid, perhaps in the form of stewed tea,
in order to precipitate the alkaloid. A hypodermic injection of
morphia mitigates most of the symptoms. Pilocarpine is also
recommended. |
ETHER INEBRIETY.
In some villages in North Ireland and in East Prussia certain
beverages adulterated with ether find favour among the poorer
classes on account of the hilarious intoxication which they
rapidly induce at a small cost. Half a pint of ether per diem is
not uncommon. There is sudden exhilaration with motor excite-
ment which rapidly passes off, leaving the patient dull and
stuporose. He sleeps the drug off and is apparently none the
DRUG HABITS 387
worse next day for his drinking-bout. Usually he is an old
alcoholic, so that it is difficult to ascertain the specific effects of
chronic ether intoxication; there seems to be a tendency to
melancholia. The underlying unconscious psychical mechanisms
are the same as in other drug habits.
PLUMBISM.
The mental phenomena induced by chronic lead-poisoning are
those of uremia and are directly dependent on chronic renal
disease simultaneously induced by the poison.
TOXIC INSANITY.
UNDER this title we have to consider mental disorders due to the
noxious influence of the products of disease, mainly infectious,
and of certain drugs, especially alcohol, to which a separate
chapter is assigned.
Inasmuch as the array of symptoms caused by excessive mental
and physical exertion, conscious worry, anxiety and fright is
precisely the same; the description of the insanity arising from
such causes is also included here, the question whether such
conditions may induce the formation of toxins or not being left
open. It would appear probable that they do; at least we
know that the adrenalin and sugar contents of the blood are
altered by such affective states.
CHAPTER XIV.
ACUTE CONFUSIONAL INSANITY.
(MENTAL EXHAUSTION AND INTOXICATION.)
In the earlier part of this volume it was stated that there are
certain individuals who, when they become fatigued, suffer from
a train of exhaustion symptoms, exhaustion being pathological
fatigue. Should such people suffer from mental disease it tends
to fall into line with the type now under consideration.
The mental disorders here described arise in predisposed
individuals as a result of severe intoxication of the cerebral
cortex by alcohol, belladonna, cocaine, chloral, Indian hemp
and other drugs; by the toxins of certain fevers, such as ery-
sipelas, influenza, rheumatism, typhoid, scarlet fever and septi-
cemia, and still more by the antibodies formed during such in-
fectious diseases;* by products of fatigue, which are created by
excessive mental or physical exertion, worry, anxiety and fright,
* Bérard and Lumiére have described this condition as occurring in
eleven cases of tetanus treated with antitetanic serum. It is fortunately
of brief duration lasting only fifteen to twenty days.
388
ACUTE CONFUSIONAL INSANITY 389
or as a result of malnutrition of the cortex from inanition,
anemia or profuse hemorrhage. Childbirth is a frequent cause
of the disorder since it may lead to exhaustion, hemorrhage or
septicemia; this insanity may also be caused by prolonged
lactation.
Neither from my own observations nor from a careful study
of Bonhoeffer’s monograph on “ Die Symptomatischen Psy-
chosen’ have I been able to convince myself of any features of
the disorder which can be regarded as even suggestive of any
specific etiological factor except, perhaps, in the case of some
poisons. The specific origin of the malady can be ascertained
only from the history or from the coexistence of symptoms of
some particular physical illness.
Physical Signs.—The patients look ill from the beginning.
Their complexion is pale and muddy. In depressed cases the
skin tends to be abnormally dry, in excited cases greasy. In all
there appears to be a special proclivity to seborrhcea sicca of
the scalp.
The general nutrition is poor. The patients lose weight and,
on admission to hospital, are frequently emaciated. The tem-
perature is often subnormal.
There is almost invariably a slight chlorosis. The pulse is soft
and the arterial tension low, even in the depressed cases; the
pulse-rate is normal or only very slightly increased. The urine
is scanty, of high specific gravity, and it may contain a trace of
albumin.
As a rule, there is little or no diminution of muscular power;
yet a few patients are physically weak and show tremor of the
fingers.
The superficial reflexes are normal except in depressed patients,
in whom they are diminished. The tendon reflexes are increased,
the knee-jerk being usually characterized by large excursion and
inactive return. The organic reflexes are unaffected.
The pupils are widely dilated, but react to light and contract
on convergence. Nystagmoid jerking is commonly seen on
extreme lateral deviation of the eyes.
Mental Symptoms.—Peripheral analgesia is almost invariably
present during some stage of the disease, is one of the cardinal
symptoms and persists usually for a fortnight or more after
the patient comes under treatment. Contraction of the visual
fields may be sometimes observed; possibly it is a constant
symptom, but it is difficult to determine SAMS ASLOLLY aes
it is present in all cases. | |
390 MIND AND ITS DISORDERS
The analgesia can be overcome by certain devices. For
example, if a spot not too far from the margin of the analgesia
be persistently stimulated by repeated pin-pricks, the patient
soon begins to apprehend the painful element in the stimulus.
Similarly, spots can be discovered where he cannot feel the pain
of an ordinary pin-prick but can feel the prick of a multiple-
pointed pin.* We shall see later that this observation helps
to elucidate the mechanism of the symptoms of this disorder. |
There is a great disturbance of the functions of perception,
cognition and recognition. Imperception occurs. If the patient
be shown a picture he is unable to say what it portrays. Of
course, the complexity of the picture necessary to elicit the
Fic. 62.—ANALGESIA IN A CASE OF ACUTE CONFUSIONAL
INSANITY.
symptom varies from case to case. Similarly the patient may
not be able to understand the import of a more or less com-
plex sentence.
Perceptual or ideational inertia is common. If the patient
be shown a series of objects, he may recognize the first one and
name it correctly, but give all succeeding objects the same
name (vide p. 126).
Hallucinations are a cardinal symptom. Commonly they are
of all the senses. The patients see in the air moving faces, devils
or flying insects, hear voices or other sounds; sometimes they
catch imaginary insects with their hands and evidently feel
* Such an implement can easily be made by pressing the points of four
or five ordinary pins through a disc of cork.
ACUTE CONFUSIONAL INSANITY 391
them between their fingers; they feel beetles crawling over them,
smell chloroform in the bedclothes and taste poison in their food.
Illusions of identity occur and the officials of the institution are
mistaken for relatives or enemies.
The patients are incapable of apprehending the nature of their
surroundings. This again is a characteristic symptom of the
disorder. Patients are, at least in severe cases, completely
disorientated. Even in mild cases, they are liable to lose
themselves in formerly well-known surroundings.
The memory is greatly disordered. Most of these patients
have no idea how long they have been in hospital and women who
have been married for years will answer to their maiden name
only. On recovery it is found that a great part of the illness is
forgotten and remains a mere blank, a mental scotoma.
This extensive disturbance of the perceptive faculties leads to
disorder of judgment and delusions arise. The patient refuses
to accept the reality of things. The hospital is a church,
monastery or theatre. Although in his own room and bed, he
believes that he has been transferred elsewhere and that an
elaborate attempt has been made to make the place resemble his
ownroom. The flowers in the room are artificial; the newspapers
are not brought from the outside world, but printed on the
premises for purposes of deceit, the news therein being false. One
patient, whom I allowed to examine my camera minutely,
refused to believe that it was a real one. Others believe that
their children are being tortured, for they can hear them scream-
ing; that they themselves are to be done to death, for they see
cartloads of bodies taken away every night; or that certain
relatives are dead, for they have been present at the inquest.
Expansive delusions occur in a few cases.
The emotional attitude varies. The majority are depressed.
Many are cheerful, abnormally hilarious and mirthful. Emo-
tional reaction is excessive in most cases, the patients being
irritable -and liable to outbursts of laughter, anger or depres-
sion associated with a flood of tears. A few stuporose patients,
on the other hand, appear to be completely apathetic.
Instinctive action is uncontrolled. In many cases the peri-
pheral anzsthesia allows the pelvic area to dominate conscious-
ness, the patients then becoming erotic or taking to masturbation,
thus exhausting themselves further and perhaps rendering their
malady incurable. A few patients, especially males, collect
rubbish. Destructiveness is common, the bedding and clothing
being frequently torn to pieces.
392 MIND AND ITS DISORDERS
On the other hand, the instincts are often in abeyance to such
an extent that the patient is wet and dirty in habit. He spits,
throws food about and smears his room with faeces.
Motor restlessness is the rule, especially during the first month
of the illness, so that the patients have to be nursed in a padded
room. Excited cases lie on the floor and pound it with their
heels and fists, or stand hammering with their closed fists on the
walls or door. Depressed patients wander about aimlessly in
a dazed condition, perhaps pulling out their hair; or they lie
quietly but rigidly in bed gazing at the hallucinatory forms
about the room. Others again curl themselves up in a corner
under bedclothes or inside their nightdress and remain motion-
less for hours together. Most of them resist all attentions, refuse
food and have to be fed with a tube.
The movements are slow and performed without any definite
aim, thus differing from the characteristic movements of acute
mania, which are quick and usually have some mischievous
purpose.
Agnostic and ideomotor apraxia occur, often with ideational
inertia or “‘ perseveration’’. The patient is shown a fountain-
pen; he pulls the end off. He is now shown a knife; he tries
to separate it in the same way into two parts by pulling at the
two ends. The same occurs with a match-box, and so forth.
Volition being in abeyance, voluntary attention is impossible.
Instinctive attention, on the other hand, is easily roused in some
cases and the patient’s thought can be diverted by merely
holding a watch, bunch of keys or other object within his field
of vision. Of course, by reason of his imperception he may fail
to grasp the full meaning and content of the percept which one
endeavours thus to induce.
On account of the lack of voluntary attention the speech is
incoherent. In severe cases it may consist entirely of disjointed
words and phrases. Rhyming incoherence is occasionally heard.
A certain amount of garrulity occurs in some of the excited cases,
but noisiness and shouting are rather exceptional.
No attempt at letter-writing is made during the earlier stages
of the disease. Later, when improvement develops, the patient’s
first letters give evidence of mental confusion. He may start
a letter fairly well; but as he rapidly tires the same sentences are
repeated over and over again (ideational inertia) and the epistle
ends in a series of disjointed phrases. The calligraphy is
puerile, mistakes in spelling occur and blots are a frequent
accompaniment.
ACUTE CONFUSIONAL INSANITY 505
VY ethdemn (hen
Year Dad wre
J “ware ae re
hocohaahs
ay. fou u to PA hg reel
eee OL, 4k ohale
394 MIND AND ITS DISORDERS
Sleep is poor and occupies but a few short periods during the
earlier hours of the night.
The acute stage of the disease lasts about three months, at the
end of which it is found that sleep has improved under treatment
and that analgesia has disappeared. The motor restlessness
tends to decrease, but persists with occasional remissions for
four or five months. During this time perception improves,
the patient gradually becomes orientated and the hallucinations
and delusions vanish. Even at this stage emotional outbursts
are liable to arise and the patient is easily confused and may
be incoherent in conversation. These symptoms, however, dis-
appear during the next six months as the patient rapidly puts
on flesh. Even during convalescence fatigue is easily induced
and undue exercise is liable to bring about a relapse.
Varieties.—At least five varieties may be recognized:
I. The depressive form associated with motor restlessness.
This is the commonest variety.
2. The excited form, with happiness, hilarity, motor excitement
and sometimes exaltation.
3. The stuporose form in which the patient remains quiet and
rigid, the rigidity affecting all the muscles of the trunk and limbs.
These patients usually suffer from terrifying hallucinations, and
are consequently in a state of extreme depression.
4. Kraepelin distinguishes a separate variety which he calls
“collapse delirium ’’. This is characterized by the shortness of
its duration, since it rarely lasts more than a fortnight or a
month.
5. The catatonic form closely resembling the katatonia of
dementia precox. Such patients present the symptoms of
negativism, flexibilitas cerea, echopraxia, echolalia, antics,
repetitive movements and verbigeration.
There is an intermittent form of the disorder, the patient
suffering from many attacks in the course of his life. Each
attack leaves him more weak-minded and he ends in profound
dementia. Analgesia is less constantly found in this class. It is
possible that a more intimate study of this variety may cause
many of the cases to be relegated to the maniacal-depressive
group.
Diagnosis.—The above varieties are to be distinguished from
melancholia, mania, anergic stupor and dementia praecox by
paying due attention to the state of the patient’s perceptive
powers, orientation and memory. I regard it as the most
difficult problem in the diagnosis of mental disease to differen-
ACUTE CONFUSIONAL INSANITY 395
tiate between the catatonic variety of confusional insanity and
that of dementia przcox, especially when the patient does not
speak and therefore gives no clue as to the state of his per-
ception, orientation and memory. The presence of peripheral
analgesia argues for confusional insanity. If the malady can be
definitely ascribed to some recognized etiological factor of acute
confusional insanity the fact should have considerable weight
in making a diagnosis. In chronic cortical atrophy hallucina-
tions do not occur. Certain epileptic states are liable to resemble
this insanity, but in such cases a history of convulsions is usually
obtainable.
Prognosis.—The majority of these patients make a fairly
complete recovery in six to twelve months. A few cases last
longer, up to two years. About Io per cent. remain permanently
demented. Kraepelin puts the duration at four months, the
discrepancy being accounted for probably by the fact that bed-
treatment is more rigidly adhered to on the Continent. The
disease occasionally proves fatal.
The best guide to prognosis is the depth of dissolution. Loss
of control of the most recently acquired instincts is of minor
importance. On the other hand, the prognosis is grave for
patients who are persistently destructive and dirty in their habits,
and for those who during the acute attack lose the instinct for
speech and for locomotion. In estimating the probable duration
of the disease the above rules do not seem to apply. The writer
is fairly accurate, as a rule, in predicting the duration of a case,
but unable to frame any rules; he can only ascribe this faculty
to an intuition born of experience.
Pathology and Morbid Anatomy.—While fatigue is an intoxica-
tion of the tissues by the paralyzing products of muscular meta-
bolism, exhaustion is regarded as a process of self-destruction of
nervous tissue through its own activity, katabolism being in
excess of anabolism. In other words, exhaustion is a morbid
process taking place in the cerebral cortex, in which the amount
of consumption exceeds that of repair.
Such a condition of affairs can only exist where the supply
of nutrient pabulum is deficient. Now the primary nutrient
pabulum of the cortical neurons is the intracellular trophoplasm
(chromatoplasm) and we learn that histological examination of
the brains of patients who have died from acute confusional
insanity reveals disintegration of the trophoplasm of the cortical
neurons. The Nissl granules are deficient and powdery (chro-
matolysis). There is in addition some staining of the achromatic
396 MIND AND ITS DISORDERS
substance and the nucleus may be eccentric in position (achro-
matolysis). In some cases there is cedema of the pia-arachnoid
and there may be found on microscopical examination diapedesis
of leucocytes into the perivascular spaces. It is held that
chromatolysis is a recoverable condition, but that achromatolysis
means permanent damage to the neuron because it signifies
destruction of the kinetoplasm. | }
There are certain considerations, however, which suggest that
the mechanism underlying the cardinal symptoms of this disease
is an increase of synaptic resistance more or less throughout
the nervous system. Let us examine each of these symptoms in
turn: analgesia, hallucination and imperception.
I have already remarked that repeated and multiple stimuli
overcome the resistance which underlies the analgesia. The con-
clusion from such experience is that this resistance is at the
synapses, and not in the neurons; for there are no observations to
show that a strong stimulus will overpower a block in a neuron
more readily than a weak one. Indeed all the available evi-
dence negatives such a suggestion and Sherrington’s experiments
on the scratch reflex of the dog show that multiple subliminal
stimuli will overcome synaptic resistance.
Again, on p. 137 we came to the conclusion that one of the
elements in the mechanism of hallucination is dissociation of the
peripheral neurons from the central nervous system. This was
how I put it some twenty years ago; I would now say that there is
increased resistance at the synapses between the peripheral and
more central neurons.
Lastly, it occurred to me to try the effect of some drug which
would diminish the resistance at the synapses in these cases.
The drug which stands pre-eminent for such a purpose is
strychnine, and I found that in several mild cases of this disorder
Niv. of the liq. strychnine subcutaneously injected three times
a day abolished the anesthesia and the hallucinations and
rendered the patient’s perception perfectly clear in a most
remarkable manner. In two or three cases this treatment
proved the turning-point in the patient’s illness.
The conclusion is that in acute confusional insanity there is
an increase of the normal resistance at the synapses to the pas-
sage of neurokyme. But the synapse is not a thing in itself; it
is merely a site of contact between two neurons, and we can
only suppose that any disturbance of its functions must be due to
some affection of the neurons themselves. It may, therefore, quite
well be that such observations are of purely academic interest. —
ACUTE CONFUSIONAL INSANITY 397
Treatment.—In the first instance cerebral activity must be
reduced to a minimum and the supply of nutriment raised to
a maximum. In other words, the patient must have plenty of
rest and plenty of good nourishing food.
Rest is to be obtained by keeping the patient in bed during the
greater part of his illness. If he will not remain in bed, the habit
of quietude may often be induced by a preliminary course of
prolonged baths.
It is usually necessary to resort to drugs to promote sleep and
reduce motor excitement. For this purpose paraldehyde and
amylene hydrate are the best, 14 drachms being administered
night and morning (two or three tablets of dial serve the same
purpose); these patients are especially liable to develop symp-
toms of poisoning if they are treated with sulphonal. Hydro-
bromide of hyoscine (z$5 grain) or liq. morphine bimeconatis
(4 drachm) three times a day may also be found a useful sedative.
It must be remembered that these cases are easily susceptible
to fatigue long after the symptoms have apparently disappeared.
It is therefore a great mistake to get the patient up too
soon, for this may induce relapse. Most cases require, at
the very least, two months’ continuous rest in bed. It
need scarcely be insisted that restraint should be avoided,
especially that most objectionable form, being “‘ held down ”’ by
nurses.
The diet should at first consist of 3 or 4 pints of milk, enriched
by the addition of cream, and four to six eggs daily. The mode
of preparation is, of course, to be varied. It may be as custard
or hot bread-and-milk, or the milk may be flavoured with coffee
or cocoa. Beef-tea and broth may be given between meals.
In cases where the digestion is poor the food may be lightly
peptonized. Tube-feeding is frequently necessary and should
on no account be shirked. As the appetite improves solid food
may be gradually substituted. Alcohol in the form of brandy,
port or stout, according to the patient’s requirements, is a useful
adjuvant. Apart from its stimulating properties it promotes
sleep and improves the appetite.
Iron in some form which does not disturb the digestion is
indicated in nearly all cases; the scale preparations are probably
the best for this purpose. Constipation should be combated
by the judicious use of purgatives, and intercurrent symptoms
treated on general medical principles, as they arise. In threat-
ened collapse the physician should resort to copious intravenous
injection of normal saline solution.
398 MIND AND ITS DISORDERS
Massage may be usefully employed for patients who are
sufficiently restful to allow it and, when the general nutrition
is thoroughly restored, a favourable termination can frequently
be accelerated by the judicious use of such tonics as
strychnine. |
CHAPTER XV.
ALCOHOLIC INSANITIES.
Ir will not have escaped the reader that the description of acute
confusional insanity is applicable to delirium tremens but,
inasmuch as other varieties of alcoholic poisoning have to be
recognized, it has been decided to consider this group as a
separate chapter. It is not strictly correct, however, to regard
alcoholic insanity as a distinct disease.
Etiology.—The determining factors of alcoholic insanity are
(1) The nature and quantity of the alcoholic beverage employed
and (2) the character of the individual who drinks it.
Several investigators have found degenerative changes in the
cortical nerve-cells of animals to which large quantities of ethyl
alcohol have been given. We must therefore hold this substance
responsible in a large measure for the deleterious effects of alco-
holic beverages on the nervous system. These effects appear
to some extent to increase part passu with the degree of con-
centration; hence we find that spirits are by far the most per-
nicious form of alcoholic beverage. General experience, however,
points to the conclusion that the higher alcohols and aldehydes
which, according to certain revelations some years ago, are
contained in many varieties of whisky and brandy, are much
more poisonous than ethyl alcohol. It would be interesting
to know if those degenerates who take their alcohol in the form
of eau-de-Cologne, lavender-water, tooth-washes or spirit from
the specimen jars of anatomical museums ultimately suffer from
chronic alcoholic insanity; I have not heard of sucha case. The
disease undoubtedly occurs in other than spirit-drinkers; but the
other forms of alcoholic beverage, even when taken in large
quantities, appear to be much less potent to produce insanity.
Even our three-bottle ancestors, whose excesses are reported to
have been very productive of gout, are not, so far as I am aware,
said to have been especially liable to insanity.
Although experience teaches that the daily ingestion of alcohol
is conducive to general health and well-being, several German
experimenters have found that increased motor excitability and
399
400 MIND AND ITS DISORDERS
diminution of the mental powers are discoverable for some
thirty-six hours after the ingestion of about two litres of German
beer. The conclusion from such findings is that everybody who
takes alcohol regularly with his meals is permanently under its
influence. It therefore becomes somewhat difficult to decide
what quantity of alcohol is to be called excessive. A person’s
sensations may be quite unreliable, for some people can drink
enormous quantities of alcohol for years without ever being, in
the popular sense, the worse for drink. Yet the ultimate result
is permanent damage to the nervous system. Such a person
should ascertain how much alcohol his tissues are capable of
oxidizing and make it a rule to keep within that quantity. If
he drinks more than this, the excess is excreted and may be
detected in the breath four or five hours after its ingestion. It
has been demonstrated that alcohol is also excreted in the urine,
sweat and bile and that it may be detected in the blood. As
long ago as 1839 Percy demonstrated its existence in the ven-
tricles of the brains of animals poisoned with alcohol and showed
that the nervous tissues had a peculiar affinity for this drug.
Most people are capable of oxidizing about 2 ounces of alcohol
in the twenty-four hours; this quantity is contained in about
4 ounces of brandy, whisky, rum, gin or liqueur; 10 ounces of
port, sherry or Madeira; a pint of champagne, hock or claret
or 2 pints of beer. It need scarcely be urged that, if these
maximum quantities be taken, it is not desirable that they be
taken at one sitting if it is intended that they should be oxidized
and produce no pharmacological effect. Rivers and Webber
have shown that doses of alcohol up to 20 c.c. (about 6 drachms)
have no influence in increasing or diminishing muscular work.
The brain of a normal person possesses the power of resisting
the effect of a certain amount of alcohol, which is usually much
more than that above mentioned and varies with different indi-
viduals. If a larger amount than this be taken the result is
physiological inebriation. In some individuals, however, the
capacity of resistance to alcohol is very small indeed: with them
the ingestion of very small quantities leads to pathological
inebriation.
An intolerance of alcohol may be congenital or acquired. It
is congenital in persons with a neuropathic inheritance, especially
in epileptics and patients who are subject to the intermittent
and periodic forms of insanity or suffer from dementia przecox.
It is acquired by many persons who have been subjected to the
influence of prolonged fevers or sunstroke, have received at
PHYSIOLOGICAL INEBRIATION 401
some time a violent blow on the head or have been guilty of
frequent alcoholic excesses in previous years. In this last case
the result may be anaphylactic in origin.
PHYSIOLOGICAL INEBRIATION.
This condition is a passing disturbance of the physical and
mental functions, induced by a poisonous dose of alcohol. At
first there is an increase in the frequency of the pulse and respira-
tion with general dilatation of the arterioles and consequent
lowering of blood-pressure. This gives rise to a feeling of
warmth and well-being. Muscular power is increased and the
onset of muscular fatigue delayed, as shown by the ergograph.
The imagination and flow of ideas are stimulated.
On the other hand the faculty of volition is reduced, including
the capacity for mental work, voluntary attention and the
capacity for passing judgment in the course of an argument.
The moral sense and the power of self-criticism are diminished.
There is a tendency to the formation of illusions and a certain
_ amount of imperception occurs. In the domain of vision this
may be partly due to crossed diplopia.
The emotional tone varies in different individuals. Most
people are jovial, some are hilarious, others are depressed and
perhaps tearful; some are arrogant and querulous, others again
are suspicious or sentimental.
Similarly the disorder of speech varies in different individuals.
Some are garrulous and incoherent, others are dumb, and yet
others eloquent. Articulation is difficult and indistinct.
When the intoxication is more advanced the drunkard loses
control of his limbs and staggers in his attempts to walk. The
frequency of the pulse and respiration now become diminished.
There is well-marked anesthesia, external impressions fail to
reach the sensorium and the patient falls into a deep sleep or
coma. Recovery usually takes place after several hours, leaving
a sense of malaise with headache and loss of appetite. Death
sometimes occurs from paralysis of the respiratory centre.
To be “drunk in a public place’’, “drunk and incapable ”’
and “drunk while in charge of a motor-car’’ are indictable
offences and recent arrests under the third category have raised
the question of differential diagnosis on several occasions. It
appears that quite a moderate dose of alcohol will render some
persons unable to manage a motor-car and may thus cause them
to be a public danger, especially those who already have some
26
402 MIND AND ITS DISORDERS
organic affection of the nervous system or have previously suffered
from neurosis, particularly war neurosis. For the public safety
and for their own reputation it behoves such people to become
teetotallers. The diagnosis depends upon the presence of several
of the above-mentioned symptoms. There is no one pathog-
nomonic sign of drunkenness, but any man in the street can ©
diagnose the malady, given a sufficient number of obvious signs.
Treatment consists in washing out the stomach and adminis-
tering a purge with sal volatile or hot coffee, perhaps reinforced
with 5 grains of caffeine. Occasionally it becomes necessary to
resort to artificial respiration.
PATHOLOGICAL INEBRIATION.
This disorder is usually caused by much smaller quantities
of alcohol than are necessary to induce the condition above
described; in some cases one or two glasses of beer are sufficient.
It arises in patients with congenital or acquired neuropathic taint.
The commonest form, mania a potu, is an attack of intense
motor excitement. The patient appears. to be in a state of
semiconsciousness and to have absolutely no control of his
actions. In his violent fury he may attempt homicide or
suicide, especially by precipitation. Indecent exposure, carnal
assaults on women, incendiarism and thefts are common, the
patient remembering little of such incidents on his recovery.
There is usually some tremor of the hands and tongue and
difficulty of articulation. The gait is uncertain and slightly
reeling, but the patient is capable of steadying himself when he
finds that this symptom is attracting attention. The knee-jerks
are diminished. Recovery usually takes place in a couple of
days without treatment.
Tanzi mentions an apoplectic form which sometimes leads
to coma and death. It would therefore be well to wash out
the stomach should the patient be seen sufficiently early.
Pathological inebriation occasionally resembles the physio-
logical variety, the only difference consisting in the small quan-
tity of alcohol which has induced the condition. Transient
depression with suicidal tendency sometimes occurs.
DELIRIUM TREMENS.
Delirium tremens is an acute disorder resulting from chronic
alcoholism. A single alcoholic bout will not produce delirium
tremens unless the patient has been continuously under the
influence of alcoho] for at least some weeks previously.
DELIRIUM TREMENS 403
An attack may be precipitated by any kind of shock, especially
physical injury, such as a fracture or a surgical operation, and
acute fever, such as influenza, pneumonia or typhoid. In the
treatment of these conditions the patient is generally put to bed
and deprived of his usual excessive quantity of alcohol; it is
then found that delirium tremens develops. This suggests that
the disorder is due, not to alcohol, but to the sudden deprivation
of alcohol. This doctrine also receives support from the usual
history that the patient has taken no alcohol for several days
previous to his illness, but this might be explained by the fact
that one of the earliest symptoms is a dislike for stimulants.
We learn from the authorities of prisons that suddenly enforced
abstinence does not invariably in itself induce an attack, even
in the worst drunkards. Moreover, we are bound to admit that
we see many patients who have drunk hard right up to the time
when they come under observation. Loss of appetite for food
is a feature which has given rise to a probably mistaken notion
that failure to take nourishment is an etiological factor, but this
is one of the early symptoms of the disease.
It is probable that delirium tremens is not due to the direct
action of alcohol, but rather to a secondary auto-intoxication;
otherwise the condition should pass off within forty-eight hours
of the last bout, by which time almost every vestige should
be eliminated; whereas clinical experience teaches that the
disease lasts from four days to three weeks or more. It’ is
now well established that the introduction of any poison into
the system stimulates the tissues to throw out defensive substances
of various kinds and it seems likely that, in the case of chronic
alcoholism, these would-be defensive substances, being produced
in excess, are at least partly the cause of delirium tremens.
Another etiological factor is the predisposition of the individual
to this particular form of alcoholic insanity, since we find that
delirium tremens is liable to occur several times in the same person.
Onset.—The first indications make their appearance in the
night. The patient is restless and sleepless. What snatches of
sleep he can get are disturbed by horrifying dreams. By day
he is restless, suspicious, irritable and timid.
Physical Signs.—The general aspect of the patient is charac-
teristic. His face is flushed, his conjunctive suffused and his
skin bathed in sweat. During the first few days there may be
a rise of temperature: this is not above 100° F. as a rule, but
I have seer it as high as 104° F.
The flow of saliva is increased, the tongue is therefore moist
404 MIND AND ITS DISORDERS
and but slightly furred. The appetite is poor and the patient
may absolutely refuse food so that he has to be tube-fed; there
is even a revulsion from alcohol. Constipation is the rule.
The pulse is frequent, soft and full in the early stages; later
it tends to become small and feeble. The respirations are deep —
and slightly increased in frequency; the breath has a heavy,
offensive odour. . .
The urine is scanty and high-coloured and its specific gravity
is raised; it frequently contains albumin and casts. The blood
shows a general leucocytosis with diminution of the eosinophiles.
The pupils are at first contracted, but they usually become
dilated as the disease progresses. There is general motor weak-
ness associated with tremor. This tremor is an exaggeration of
that of the habitual drunkard. It is said to occur first in the
feet. It is rather coarse, increases on movement and affects the
fingers, lips and tongue most; but in a severe case it may he
detected in any part of the body by placing one’s hand there.
The hands and fingers are in constant movement, a symptom
which may be taken to indicate irritation of the cortex by
toxins in the blood. The knee-jerks are usually diminished, in
some cases they are exaggerated and rectus clonus occurs. The
superficial reflexes are diminished or absent.
Mental Symptoms.—Many authors state that there is a general
hyperesthesia during the early stages. This may be so; but
later in the disease, especially in the more protracted cases which
are seen in mental hospitals, there is peripheral analgesia and con-
traction of the visual fields.
The most striking disturbances are in the domain of percep-
tion. Hallucinations, especially visual, dominate the clinical
picture. The patients see enormous spiders, rats, snakes,
vultures, mannikins with ugly faces, grimacing devils with
pitchforks and all manner of strange beasts, terrifying and
grotesque in their hideousness. These hallucinatory objects are
usually slate-blue in colour, hence the popular name “ blue
devils’. A piece of red glass placed before the patient’s eyes
does not alter the colour of these images. The hallucinations
of hearing are also of a terrifying nature, such as revolver shots,
the clatter of engines of torture and voices saying “‘ Kill him !”’
“Let us skin him!” “Murderer!” etc. Cutaneous hallucinations
are in keeping; the patient feels the sting of the serpent’s fang, the
dog’s bite, the stroke of the knife, stabs and sensations of burning.
Hallucinations are easily induced in such patients. If you
point to the floor and say “‘ What is that ?’’ he will answer “ A
DELIRIUM TREMENS 405
snake ’’, “A dog”’, “ A flower ’’, according to the nature of the
image induced. Pressure on the closed eyelids will evoke moving
pictures. If this be done and the patient asked what he sees, he
will answer somewhat in this fashion: ‘‘I see a horse. Here
comes a man; he is mounting the horse; now he is riding towards
me’ etc. Or if you say to the patient, ‘“‘ Listen! what is that
noise ?”’ he will answer “Soldiers ’’, ‘‘ Music’, ‘‘ The dog bark-
ing ’’, the answer varying, of course, with the nature of the
hallucination. Hallucinations of other senses may be similarly
suggested. This feature is almost peculiar to delirium tremens;
but I have observed it in a few other cases in which hallucinations
were a prominent symptom.
In spite of the extraordinary grotesqueness of many of the
hallucinations the patient invariably accepts them as real. He
is unable to recognize their true nature. Yet in the midst of
the delirium a sharp word will bring him to his senses and he
will converse rationally for a few moments.
Imperception is another prominent symptom. There is
partial psychical (not retinal) colour-blindness, so that the
patient confuses greens and blues, especially yellowish and
greenish blues. Objects cannot be recognized, at least if they
are at all out of the ordinary, and if the patient be shown a
simple picture he is unable to tell what it portrays. Similarly
he is unable to understand simple commands if they be uttered
in a monotone without his being shown what to do. If for
example you say to him “ Put your left little finger on your nose ’’,
he is utterly confused as to your meaning. Motor and agnostic
apraxia are present in all severe cases.
Disorientation is constant. The patient may look round his room,
perhaps the padded room of an asylum, and out on the asylum
grounds and yet believe himself to be inhisown home. He cannot
tell the time of day, the date, month or even in some cases the year.
Except for the distracting effect of hallucinations the flow of
ideas is coherent and obeys the ordinary rules of association.
The memory for recent events is practically nil; the events of
former years are well remembered.
The general emotional tone dependent to a large extent on
the tremor is one of timidity, anxiety and fear. Emotional
reaction is good but dominated by hallucinations. In those
rare cases in which the hallucinations are of a pleasant nature
the patients may be more or less cheerful.
At the height of the disease the instinctive motor system
dominates action and volition proper is in abeyance. Actions
406 MIND AND ITS DISORDERS
tend to be impulsive, are frequently of a violent character and
are mostly initiated by hallucinations. Homicidal and suicidal
impulses sometimes occur.
Actions which have become automatic are also in evidence;
hence occupation delirium is almost a constant feature. The —
butcher busies himself in hanging up carcasses, the carpenter saws
imaginary pieces of wood, the small shopkeeper spends his time
putting up and taking down the shutters of his shop and so on.
Attention can always be reflexly aroused with a little trouble,
e.g., by shaking the patient and speaking sharply to him; but
active voluntary attention does not occur during the height of
the disorder.
Except for occasional incoherence and the erroneous choice
of words (paraphasia) speech is normal. Articulation, on the
other hand, is usually tremulous and blurred, the greatest diff-
culty being with the consonants.
Insomnia is absolute, at least in those cases (the majority) which
last three or four days. The disease terminates, however, in a pro-
found sleep. Inthe prolonged cases sleep returns more gradually.
The patient’s subsequent recollection of the various details of
his illness is very imperfect. This characteristic of the disease
probably accounts for the fact that such an experience has no
deterring effect on the chronic drunkard. The illness being over
he soon lapses into his old habits. In all too many cases the
disorder again and again recurs.
Prognosis.—Nearly all the cases make a complete and rapid
recovery. In a certain number, however, it is found, on re-
covery from the acute condition, that the patient is an alcoholic
dement or that there is a substratum of chronic mania or some
of the other alcoholic disorders hereinafter described. The
disease terminates fatally in about 5 per cent. of the cases,
usually from cardiac failure. This result is to be feared when
the sphygmographic tracing shows an “irregularly undulating ”’
character (Anstie). The prognosis should be guarded when a
large amount of albumin is present in the*urine and especially
when the daily amount of that secretion begins to fall. In a few
cases death occurs from convulsions.
Treatment.—Delirium tremens should be treated in a more
or less darkened room in which there is a plentiful supply of
fresh air. If these conditions can be obtained in a padded room,
so much the better. The patient should be persuaded to remain
in bed; but it is better to allow a certain amount of restlessness
than to exhaust him by constant struggling.
DELIRIUM TREMENS 407
Plenty of nourishment should be administered in small doses
at frequent intervals. Bread-and-milk or milk alone is the best
form. It is better to avoid soups, beef-tea and mince, lest such
articles of diet should throw too much strain on the kidneys.
Bread-and-butter, vegetables and fruit are permissible if the
patient can be induced to take them. If, as seems probable,
delirium tremens is caused by anti-alcohols, physiological anti-
dotes to alcohol produced by the tissues, it would appear to be
reasonable treatment to neutralize them by allowing a little
alcohol to the patient and this idea is supported by practical
experience. It is found that the disease is mitigated and indeed
that life is sometimes saved by giving two or three ounces of
brandy daily at first and then gradually reducing the amount so
that the patient is taking no alcohol at all by the sixth day.
The tapering would, of course, be more rapid than this in mild
cases. Some authorities are of the opinion that this administra-
tion of alcohol prolongs the course of the disease; I do not agree.
The only medicines which seem to be required are hypnotics;
but these patients are so remarkably tolerant of hypnotics that
only the most alarming doses are at all effectual. Anstie used
to give as much as 2 drachms of chloral hydrate in the twenty-
four hours. It seems to the author that three nights of insomnia
are likely to prove much less dangerous to the patient’s life than
such enormous doses of a cardiac depressant.
If, however, a hypnotic appears to be imperative, paraldehyde
or amylene hydrate in doses of 14 drachms or sulphonal in
30-grain doses nightly are to be preferred.
Should the secretion of urine begin to fail infusion of digitalis
in 4-ounce doses every three hours is indicated. Some of the
older physicians used to regard this drug as a specific for delirium
tremens.
In spite of the most careful treatment we occasionally en-
counter cases in which collapse threatens about the third day,
collapse which appears to be due to the sudden deprivation of
alcohol. In such circumstances it becomes necessary to allow
4 ounces of brandy daily for a short time. The effect is nothing
short of marvellous. Here indeed we have a condition in which
the life of many a patient may be saved by means of “a hair of
the dog that bit him ”’.
Chloral Delirium Tremens.—Delirium tremens is occasionally
caused by the abuse of chloral hydrate. At the present day
when there is such a multiplicity of hypnotics accessible to the
general public, chloral delirium tremens appears to be much less
408 MIND AND ITS DISORDERS
frequent than it was twenty years ago when the number of
known hypnotics was more limited. I have never seen a case.
In its clinical aspect the disease differs in no essential par-
ticulars from the alcoholic form. It is said that the tremor |
caused by chloral is finer than that caused by alcohol and that
the odour of the breath at the onset of the disease is that of
chloroform. It follows that the physician must usually rely
on the previous history of the patient in order to make a correct »
diagnosis.
POLYNEURITIC INSANITY.
KoORSSAKOW’S SYNDROME.
I place the description of polyneuritic insanity among the
alcoholic insanities because alcohol is the most common cause
of the disorder. Korssakow obtained. an alcoholic history in
three-fifths of his cases. Other causes are phthisis, influenza,
septic infection, diabetes and chronic poisoning by arsenic, lead,
mercury or carbon bisulphide. Dupré reports that he has known
the disease to be caused by intensive mercurialization for syphilis.
The disease occurs more frequently in women than in men
and usually in adult life. The earliest case which I have observed
was that of a girl aged fourteen who developed the disease
from taking large doses of arsenic for chorea and I have seen two
similar cases under twenty years of age. Neuropathic heredity
is fairly frequent.
The disease, as its name denotes, is a mental disorder asso-
ciated with peripheral neuritis. While the insanity is charac-
teristic, the neuritis differs in no way from neuritis unaccompanied
by mental symptoms. The muscles of the limbs are tender
while the skin over them is anesthetic or hyperesthetic. There
is either inco-ordination or paralysis of movement. The tendon
reflexes are absent or, less frequently, exaggerated and there
may be some nutritional disturbance such as “ glossy skin ”’ or
splitting of the nails. In the alcoholic cases nystagmus is
common and central scotomata may occur. For a fuller account
of neuritis the reader must refer to works on general medicine.
The appetite is poor and the patient loses weight, this loss being
partly due to muscular atrophy consequent on the neuritis.
Mental Symptoms.—The mental symptoms appear somewhat
suddenly, sometimes with an attack of delirium tremens. There
are commonly a few hallucinations of vision during the early
stages of the disease, but they are not a prominent feature in
the clinical picture. Imperception is well marked, especially in
POLYNEURITIC INSANITY 409
the domain of vision; the patients may not be able to recognize
familiar objects and they cannot always take in a situation por-
trayed in a drawing. They usually mistake identities and are
disorientated in time and place.
There is commonly some predominant emotional tone which
varies from patient to patient, such as depression, hilarity,
anger, anxiety, or surprise. Nevertheless emotional reaction is
normal or perhaps exaggerated, the patient weeping or crying
on trivial provocation. Instinctive attention is normal, but
voluntary attention poor. In spite of a considerable degree of
mental confusion, instinct and volition are but little affected.
Disturbances of memory are the most pronounced feature of
the disease. The memory of incidents which occurred prior to
the illness is fairly good, but the patient is unable to store up
new impressions (anterograde amnesia). There is consequently
profound loss of memory for recent events.
It is in this disease that so-called faramnesia occurs most
characteristically—illusions of memory and illusions of recogni-
tion. The most common illusion of memory is that the patient
believes that he has been out for a walk when he has not left
his bed or that he has just received a visit from some relation
when nothing of the kind has occurred. The most common
illusion of recognition is that he recognizes his present environ-
ment as having been previously experienced. He will say that
he has been in the hospital before when it can be proved that he
has not; or perhaps he erroneously recognizes some of the atten-
dants as old acquaintances.
It would appear from the following incident that illusions
of memory may sometimes be suggested to these patients. One
morning I asked the patient B. whether he had been out for
a walk. He told me he had been up the Kennington Road with
W., another patient suffering from polyneuritic psychosis, to
pawn his watch. Knowing well that neither patient had been
outside the grounds I confronted B. with W. and asked “‘ Have you
been out with B. this morning ?’’ Tomy astonishment, W. replied
“Yes, doctor: I went with him up the Kennington Road to pawn
his watch’”’. There was no attempt to deceive on the part of these
patients; both really believed that the incident had taken place.
Suggestibility in these cases is also shown by the readiness
with which they will believe the most improbable tales. I
remember a patient at Bethlem to whom I remarked “ I under-
stand that you had to row across the lake to the funeral yester-
day’’. He accepted the suggestion and even gave me details.
410 MIND AND ITS DISORDERS
As in all alcoholics there is poverty of judgment and of the critical
faculty. Nevertheless fixed delusions are rare.
Speech and articulation are usually unaffected.
The patient is sleepless for a week or two at the beginning of
the disease, but unless the pains in the limbs are troublesome
the insomnia soon passes off.
Clinical Varieties.—The clinical picture varies somewhat with
the prominence of this or that symptom. The French school -
recognizes amnesic, confusional, delusional, anxious and demented
forms of the disease. Such a classification appears to be un-
necessary. On the other hand it is important to recognize that
the disorder above described sometimes occurs without any
clinical signs or symptoms of peripheral neuritis.
Prognosis.—Kecovery generally takes place in six to twelve
months, but the disease usually leaves a certain amount of
mental enfeeblement, sometimes profound enough to necessitate
permanent care in an asylum. JDeath from cardiac failure
occurs In a few cases.
Morbid Anatomy.—Patients who have died of this disease
show fatty degeneration of the liver, kidneysand heart. There
is usually some cedema of the meninges and the cerebral cortex
is thinner than natural; otherwise macroscopic examination of
the nervous system reveals nothing abnormal.
In those cases in which there is a certainamount of chronic
meningitis, mild lymphocytosis may be detected in the cerebro-
spinal fluid. This may be ascertained by means of a lumbar
puncture during life.
Microscopical examination of the cortex cerebri reveals atrophy
of the tangential fibres and degeneration of nerve-cells, which
is best seen in the giant-cells of Betz. The degeneration is
rather characteristic; the cell-body is swollen, the nucleus
swollen and eccentric in position and there is perinuclear chroma-
tolysis. Subsequently, the nucleus becomes adherent to the cell-
wall, shrinks and disappears; then chromatolysis takes place in
the periphery of the cell-body. Similar changes may be observed
in the large motor cells of the anterior horns of the spinal cord.
This form of degeneration is that which takes place when the
axis-cylinder of a neuron has been damaged (réaction a distance).
From these observations it is to be concluded that the brunt
of the battle with the toxic agent which induces the disease is
borne by the nerve-fibres of both the peripheral and central
parts of the nervous system and that the cell changes are
secondary to the fibre changes.
Hic: Waa. BrEtTz CELL IN A STATE OF AXONAL REACTION
(REACTION A DISTANCE) SUCH AS IS PRODUCED BY SEVER-
ANCE OF OR INJURY TO THE AXON.
In this case there is advanced chromatolysis beginning
in the central part of the cell and spreading outwards, and
the nucleus is displaced and shrunken. It is often impossible
to differentiate early stages of this change from the immature
form represented in Fig. 59. [Negative kindly lent by Dr.
John Turner of Brentwood Asylum. ]
To face p. 410
F me a 7 | . a
UH ‘ | | ‘ 7 =
- : : i 7 - . a
: ¥
‘
14>
ALCOHOLIC PSEUDOPARESIS A4II
In some subjects the peripheral nerves are less resistant than
the cortical fibres to the action of a toxin and multiple neuritis
occurs; in others the cortical fibres and peripheral nerves are
equally vulnerable and we have a typical case of the polyneuritic
psychosis; in a third class the cortical fibres are less resistant
than the peripheral nerves with the result that the mental dis-
order occurs but is unassociated with multiple neuritis.
Treatment consists of prolonged rest in bed and improvement
of the general nutrition by means of a plain liberal diet with
plenty of milk. Alcohol and other drugs which are apt to induce
neuritis should be withheld.
If there is severe pain in the limbs it may be mitigated by
phenacetin or antifebrin; a water-bed is often desirable. The
nutrition of the wasted muscles may be maintained by daily use
of the constant current. When all pain and tenderness have
disappeared massage is useful and the patient may be permitted
to get up for the greater part of the dav.
SUBACUTE ALCOHOLIC INSANITY.
ALCOHOLIC PSEUDOPARESIS,
This is a subacute form of alcoholic insanity induced by
chronic alcoholism. The disorder owes its name to the resem-
blance which, in its earlier stages, it bears to general paralysis.
Epileptic and epileptiform convulsions may occur. Pseudo-
paresis is not, however, the only form of alcoholic insanity
associated with convulsions. Isolated attacks may happen to
a chronic alcoholic after a single debauch: they may usher in
an attack of delirium tremens or coma during the course of that
disease or they may be observed during the early stages of the
polyneuritic psychosis. Convulsions are especially mentioned
in this connection, because they, among other symptoms, are
liable to mislead an unwary practitioner into supposing that he
has to deal with a case of general paralysis instead of one of
_ subacute alcoholic insanity.
As in general paralysis there is well-marked tremor of the
face, tongue and hands, but the tremor has different charac-
teristics in the two conditions. Alcoholic tremor tends to affect
the upper part of the face (orbiculares palpebrarum) rather
than the lower as in general paralysis: the lingual tremor is a
rippling on the surface, not, as a rule, an ataxic trombone
movement as in general paralysis; and, while the tremor of the
fingers is coarser in alcoholism, the alcoholic is more capable of
steadying the tremor than the general paralytic.
412 MIND AND ITS DISORDERS
The alcoholic is more ataxic than the paralytic in his move-
ments: the former totters when he walks, the latter shuffles.
The pupillary light-reflex is retained in pseudoparesis except in
a few syphilitic cases, but the pupils may be unequal in size.
Contraction of the visual field is liable to be more marked in
pseudoparesis than in general paralysis and there may be central
scotomata.
The knee-jerk is usually exaggerated, but not “ floppy ”’ as in
general paralysis. In some cases associated with neuritis the
knee-jerk may be absent. The physician is then called upon to
make a differential diagnosis between peripheral neuritis and
tabes dorsalis.
In some of the neuritic cases there may be anesthesia of the
hands and feet.
Ve. Yarc Jen Ut ble
(pth, dba Shige ‘ Myplb
Monging ee
Fic. 65.—WRITING IN SUBACUTE ALCOHOLIC INSANITY.
The patient was asked to write ‘‘ Now is the time for all good men to
rally round the cause ’”’; then, “‘ She sells sea-shells and shaving-soap.”
Mental Symptoms.—These develop much more rapidly in
pseudoparesis than in general paralysis. The patient is more
confused in the early stages; he is disorientated in place and
time and there is general imperception.
Hallucinations of vision occur and are liable to take the shape
of animals; hallucinations of the other senses are not common.
There is confusion of ideas; judgment and reasoning are
almost in abeyance. Expansive delusions occur as in general
paralysis and there may be delusions of persecution.
At first the instincts and emotions are deficient and the patient
may be wet and dirty. Later, as he improves, he becomes
excessively emotional. He is incapable of sustained attention
and instinctive attention is reduced to a minimum. There is
ALCOHOLIC PSEUDOPARESIS 4T3
great disturbance of memory, the amnesia being much more
profound than in an early case of general paralysis.
Incoherence of speech is the rule. Articulation is difficult,
chiefly on account of the patient’s tremulous condition; but
there is not the same tendency to elide or repeat syllables and
words as there is in general paralysis. Similarly writing is
difficult on account of the hand tremor and general confusion.
Insomnia is well marked after the patient has slept off his
last alcoholic bout, whereas the general paralytic sleeps fairly
well when first he comes under observation.
Course and Prognosis.—The most striking difference of all
between pseudoparesis and general paralysis is that recovery
from the former condition is usually complete within two or
three months. It is true that there may be a certain amount
of residual dementia, but it is not progressive. Death occurs in
a few cases from cardiac failure or convulsive seizures.
The morbid anatomy of the condition is that of chronic alco-
holism. To a certain extent it resembles that of general para-
lysis; but there is less involvement of the neuroglial elements,
decortication does not occur on stripping the pia-arachnoid from
the cerebrum and granulation of the ventricles is uncommon.
Treatment is carried out on general lines, viz., removal of the
cause of the disease, maintenance of nutrition, relief of insomnia
and prevention of self-injury. Asa general rule alcohol is with-
held; but, should collapse threaten during the earlier stages of
the disease, alcohol will probably save the patient’s life.
CHRONIC HALLUCINATORY INSANITY.
This form of alcoholic insanity is characterized by delusions
of persecution based upon persistent hallucinations, especially
of hearing and cutaneous sensation.
Physical Signs.—In this disease the physical signs referable to
the nervous system are practically nil. There may be slight tremor
of the fingers and tongue and there is commonly exaggeration of
the deep reflexes when the patient first comes under observation:
even these signs disappear as the disease becomes established.
There is usually loss of appetite on account of an acid dyspepsia
and the bowels are constipated. There may be some enlarge-
ment of the liver and albumin may be present in the urine but
such changes are infrequent.
Mental Symptoms.—On examination sensation and perception
appear to be normal and the patients can appreciate the nature
414 MIND AND ITS DISORDERS
of their environment. At first they complain of headache and
general malaise; these symptoms soon disappear with improve-
ment of the general nutrition.
The hallucinations occur at first during the night, subse--
quently during the day as well; gradually they dominate the
whole mental life of the patient. He hears abusive, threaten-
ing and mocking voices using disgusting and often obscene
language. There seems to be a special tendency for these ©
hallucinatory remarks to have reference to sexual matters; the
patient is told that he is impotent, that his wife is unfaithful
and he is accused of unnatural sexual offences. He is threatened
with all sorts of tortures. The voices are commonly referred
to the ceiling, floor or walls; hence he believes that there are
men on the roof, telephones in the walls and electric wires under
the floor. Strange cutaneous sensations are similarly ascribed
to some form of unseen agency. The patients are mesmerized,
electrified by wireless telegraphy or X-rayed. Neologisms are
commonly employed in this condition to explain the unusual sen-
sations. One patient was “ petered in a hodge-podge ’’, another
was persecuted by “the teleform switchback confederation of
blacklegs ”’.
Hallucinations of smell occur and give rise to the delusion
that poisonous gases are instilled into the dormitory; hallucina-
tions of taste similarly induce ideas of poison.
Apart from the hallucinations the patient is capable of main-
taining a coherent train of thought, and judgment is fairly good.
He has, however, no insight into his mental condition; he accepts
his hallucinations and is full of delusions of persecution. A few
develop expansive delusions, a sure sign of intellectual ruin.
The prevailing emotional tone is one of anxiety and quarrel-
someness. The patients are difficult to get on with and are
apt to limit their remarks to the doctor to monosyllables.
Emotional reaction is good.
Instinctive and volitional action are normal but dominated
to a large extent by hallucinations. One patient used to wear a
wet handkerchief on her head to ward off the electricity, another
set “‘ booby-traps’’ at night to catch her persecutors, another
filled the keyholes with paper to keep out noxious gases; others
again perform grotesque actions to counteract the evil influences ;
one patient, for example, would vigorously turn an imaginary
handle in his heel whenever he had cutaneous pricking sensa-
tions, as if to wind himself up.
The patients are clean and tidy; they look after themselves
ALCOHOLIC PARANOIA AI5
and under supervision are capable of useful occupation. Speech
is coherent, articulation clear and writing unaltered. Sleep is
fairly good, but liable to be disturbed by hallucinations.
Prognosis.—The disease almost invariably runs a chronic
course. During the first two or three years the hallucinations
tend to become less frequent and the patient passes into a
condition of mild dementia. A few cases recover sufficiently to
be able to return home.
So far as I am aware, the morbid anatomy of this condition
has not been investigated. The cases bear a remarkable re-
semblance to dementia preecox, and we may safely say that the
reason why chronic alcoholism produces this variety of disease in
these particular patients is that deep down their psychical make-up
is that of the dementia pracox patient.
Treatment consists of the total withdrawal of alcohol, im-
provement of the general nutrition and, in the majority of cases,
permanent care in an asylum.
ALCOHOLIC PARANOIA.
This is a rare disease. It is a form of chronic delusional
insanity in which hallucinations are absent or infrequent and
play an unimportant réle. Probably it is true paranoia modified
by the effects of alcohol. It usually begins about middle life
and occurs more frequently in men than in women.
Physical Signs.—When the patient first comes under observa-
tion there are the usual signs of chronic alcoholism such as
tremor of the hands and tongue, digestive troubles and exaggera-
tion of the deep reflexes. These signs soon pass off with the
withdrawal of alcohol. After a month or so there is complete
absence of physical signs.
Mental Symptoms.—Sensation and perception are usually
normal. During the early stages there may be a few hallucina-
tions. Ideation is normal; the patients are capable of initiating
and maintaining an ordinary train of thought and their memory
is fairly good for both recent and remote events.
Disturbance of judgment is the essential feature of the disease,
the patient seeing hidden meanings in the most commonplace
incidents. As a rule, the erroneous judgments have reference
to his wife’s fidelity. He sees evidence of her infidelity in the
fact that she bows to an old acquaintance in the street, that
some man unknown to him hurries past the window, that his
wife is not prepared for his return from the office an hour earlier
416 MIND AND ITS DISORDERS
than usual or that the cushions on the sofa are not in their usual
positions.
If the disease is ushered in by an attack of delirium tremens,
he may ascribe the illness not to his admitted alcoholic excesses,
but to drugs introduced into his whisky by his wife.
I have met with one case of religious paranoia due to alcohol.
The patient was “converted” by a Salvation Army girl, took —
to preaching and ultimately, by the help of hidden meanings
in certain passages of Scripture, believed himself to be the re-
incarnation of the prophet Jeremiah. He regarded the corona-
tion stone in Westminster Abbey as God and as the stone on
which Jacob rested his head. He believed England to be the
land of Canaan, the Ark of the Covenant to be buried under a
mound in Camberwell House, the grave of Eve to be situated
in the grounds of Bethlem Hospital, and other absurdities. At
the onset of the disease he had a few hallucinations, heard the
voice of God and had visions of heaven.
The patients are capable of sustained attention. Emotional
and instinctive reaction are normal.
A jealous patient is liable to commit violent assaults on his
wife and her supposed lovers; otherwise his actions are normal.
Speech and writing are normal and the patients are capable of
useful employment in an asylum.
Diagnosis.—The disease is distinguished from true paranoia
by its rapidity of onset and absence of system in the delusional
state.
Prognosis.—The disease is incurable but not progressive. A
certain amount of improvement sometimes takes place in an
institution, but relapse occurs if the patient returns to his own
home.
The morbid anatomy of the condition has not been recorded.
Treatment consists of total abstinence from alcohol and per-
manent care in an asylum.
ALCOHOLIC DEMENTIA.
The natural termination of alcoholism is dementia. This may
develop insidiously without the patient having an attack of
acute insanity or it may be a sequel to some of the disorders
above described.
Symptoms.—Loss of sensation, when present, occurs on the
backs of the fingers; it is seldom more extensive. Hallucina-
tions and illusions are uncommon. Perception is good unless
ALCOHOLIC DEMENTIA AI7
the prolonged abuse of alcohol has resulted in severe degenera-
tion of the cerebral arteries.
The patients are irritable and difficult to get on with; they
are consequently very annoying to others. This applies equally
to cases of chronic mania resulting from alcoholism.
Loss of memory is a constant symptom and may be so pro-
found that the patient cannot remember what he has been told
a few seconds previously. I have known a patient, who had
been in the same ward for twelve months, ask an attendant
for the lavatory as if he had only just entered the hospital.
On being directed a distance of some twenty yards he would set
out, forget the direction, return to another attendant and rail
at him for not having directed him properly.
There is poverty of ideation, falsification of judgment and
warping of the reasoning faculties. Sometimes the patients
express delusions of grandeur or write cheques for enormous
sums of money.
In the earlier stages the animal instincts are allowed full
play owing to loss of voluntary control; in more advanced cases
instinct is lost after the manner described on p. 157.
In some cases the disease may be arrested by the withdrawal
of alcohol; but there is no hope of improvement in the patient’s
condition. In other cases the disease is progressive, leading
to total obliteration of the mental faculties as well as to such
motor weakness that the patient is unable to stand. Further
he may be wet and dirty, liable to develop bedsores and require
as much attention as a general paralytic; but the absence of
physical signs of that disease and the general history of the case
will prevent erroneous diagnosis.
Morbid Anatomy.—In one case of this kind which I was able
to examine post mortem, there was cedema and thickening of
the meninges which stripped with abnormal readiness from the
cortex. The cortex was thinner than natural and there was
atrophy of the tangential fibres. Neuronal degeneration ex-
tended to all parts of the cortex, the most striking feature being
an almost complete absence of chromatoplasm from the cell-
bodies. In the few cells in which chromatoplasm still remained
it consisted of a very fine dust.
It is noteworthy that it is extremely rare for cirrhosis of the
liver to be found in patients who have come under observation
for an alcoholic affection of the nervous system and, conversely,
that alcoholic insanity and neuritis are very rarely found in
patients who present themselves clinically for cirrhosis of the liver.
27
418 MIND AND ITS DISORDERS
Treatment consists of permanent care in an asylum, mental
hospital or private house where there is no possibility of access
to alcohol.
General Remarks on the Alcoholic Insanities.—Physiological
and pathological inebriation, delirium tremens, polyneuritic
insanity and perhaps pseudoparesis are clearly of a toxic nature;
but the other varieties of so-called alcoholic insanity present —
none of the features of an acute toxic confusional insanity. In
the latter varieties we find that we are dealing with psychotic
states resembling dementia precox, paraphrenia and paranoia.
Indeed they really belong there and should not properly be
included in this chapter. The only reason why they are placed
here is that alcohol appears to have played the réle of weakening
preconscious repressing forces and thus allowed the unconscious
to assert itself. In other words the patients were latent cases
of dementia precox or paranoia, which might have remained
latent, at least for a longer period, had it not been for their
seeking a solution of their unrecognized conflicts by taking large
quantities of alcohol.
In fine, alcohol is a psychological necessity for some people.
They have terribly serious unconscious mental conflicts which
can only be solved v4 alcohol or vid psychosis. Some seek the
solution of their conflicts in both ways, as we have seen in this
chapter. Such facts as these will have to be recognized by
politicians, ministers of religion and other social workers before
they can hope to diminish alcoholism and other drug habits
without detriment to the community. Indeed I am not at all
sure that the alcoholic restriction recommended for some of the
maladies discussed in this chapter is ideal treatment. In practice
it may sometimes be advisable to allow alcohol to an alcoholic
just as we allow some epileptics to have their fits and make no
attempt to diminish them with medicines.
CHAPTER XVI.
MENTAL DISORDERS ASSOCIATED WITH PRIMARY
DISEASE OF THE ENDOCRINE ORGANS.
ALTHOUGH these disorders are toxzemic in origin like the last
group the symptom-complex is usually dissimilar. They there-
fore require separate consideration.
The mental disorders here discussed are those which arise in
association with primary diseases of the thyroid, pituitary and
pineal bodies, the sex glands and the adrenals. Of these only
the thyroigenous insanities have hitherto received much atten-
tion, mainly because others are apparently of rare occurrence.
Moreover, the above-mentioned are not the only endocrine organs.
There are also the parathyroids, the thymus, the pancreas and
others; but I have not met with instances of mental disorder
originating directly from disease of these bodies, other than
cases of general exhaustion.
Although there is an accumulation of evidence that there is
an active process of atrophy in the genital glands in cases of
dementia preecox and some authorities* have found the Abder-
halden reaction to be positive to adrenal tissue in all their ex-
amined cases (sixty-nine) of epilepsy, dementia precox and
epilepsy are not included in this group because they are not
related by heredity to diseases of the genital and adrenal glands,
but to mental or cerebral maladies. For this reason I think
that affections of the genital and adrenal glands in these maladies
are to be regarded as secondary to the cerebral disorder.
TOR UERY RO ED:
MyxXCEpDEMA.
Myxcedema or hypothyroidism is a somewhat rare disease,
the essential pathological feature of which is diminution of the
internal secretion of the thyroid gland. In the large majority
of cases this is due to simple atrophy and.sclerosis of the gland
* “The Abderhalden Reaction in Mental Disease,’’ Cotton, Corson
White and Stedman, Journal of Nervous and Mental Diseases, 1917.
419
420 MIND AND ITS DISORDERS
occurring in association with the menopause or as a sequel to
some acute specific fever, acute rheumatism, syphilis or facial
erysipelas. In other cases the thyroid is enlarged by the in-
filtration of a new growth, the glandular tissue proper being
destroyed. Myxcedema sometimes appears as a sequel to ex-
ophthalmic goitre, the former enlargement of the thyroid being
replaced by atrophy. The disease begins most commonly be-
tween the ages of thirty-five and fifty-five and occurs much more ~
frequently in women than in men.
The active principle of the internal secretion of the thyroid
contains iodine and has been named “ thyro-iodine’’. It is
obtainable by boiling fresh glands in sulphuric acid (ro per cent.),
filtering off the precipitate and removing fats by trituration
with petroleum-ether and alcohol. The thyro-iodine is then
dissolved in a solution of sodium hydrate (1 per cent.) and
reprecipitated by the addition of dilute sulphuric acid. The
precipitate, a brown amorphous powder, is purified by repeated
washings in distilled water and then dried. In obtaining it
for medicinal purposes it is found that the thyroid of the sheep
gives the largest yield.
The function of this substance in the organism is either to
destroy mucinoid products formed in the tissues or to prevent
their formation. Horsley concluded from his experiments that
it transformed mucinoid products into substances which were of
some service to the organism. Since then it has been demon-
strated that there is an intimate relationship between the thyroid
and the other endocrine organs, especially with the sex glands. _
Physical Signs.—The appearance of the patient is very charac-
teristic. The subcutaneous tissues all over the body are swollen,
the aspect being that of general cedema; but the tissues do not
pit on pressure nor is there any exudation of serum on punc-
turing the skin. The face is swollen, especially the eyelids, so
that the palpebral fissure is narrowed, and there is in some
cases over-action of the frontales similar to that seen in associa-
tion with paralytic ptosis. This swelling of the face not only
hampers the movements of the facial muscles, it also obliterates
all the lines of expression. With the exception of a characteristic
flush over the malar eminences the complexion is sallow. |
The secretion of sweat being diminished, the skin is dry and
rough; the hair is dry, loses its lustre and is apt to fall out, and
the nails are longitudinally striated and liable to split.
Owing to swelling of the tongue the patient has difficulty
of articulation and of deglutition and, owing to swelling of the
MYXC@DEMA 421
vocal cords, the voice is low-pitched and raucous. Myxcedema-
tous patients are always constipated.
The pulse is infrequent, feeble, irregular and of low tension.
Examination of the blood reveals a slight diminution of the red
corpuscles and also of the white. Epistaxis is common and
difficult to arrest, menstruation is excessive and, in the case of
childbirth, post-partum hemorrhage is to be feared. Similarly
the hemorrhage from small wounds such as that left by the
extraction of a tooth is often troublesome. The temperature is
subnormal. The excretion of urea is always diminished, and
albuminuria occurs in many cases.
The patients are torpid and disinclined to occupy themselves
or to move about from place to place. The tendon reflexes are
diminished, but there are no other physical signs of disease of
the nervous system.
Mental Symptoms.—Patients suffering from myxcedema usually
feel cold; they complain especially of a subjective feeling of cold-
ness internally. Buzzing in the ears is also a common
complaint.
On examination we find that there is no loss of any form of
sensation. It has been stated by some observers that there is
delay in the transmission of tactile sensations, but it is probably
more correct to say that there is delay in the motor response
to a tactile stimulus.
The faculty of perception is somewhat deficient owing to
defect of attention, and the patients have difficulty in grasping
the meaning of simple sentences, written or spoken. Memory-
images (ideation) are not easily called up and the association
of ideas (train of thought) is impeded. The memory for remote
events is good, but that for recent events is impaired because
the attention to passing events is insufficient to allow them to
make a lasting impression (anterograde amnesia).
Emotional reaction being deficient, the patients are apathetic
and torpid. Activity of all kinds is diminished and slow. There
is little or no instinctive desire to be up and doing. As a rule
they are disinclined to talk, but this is not invariably the case.
Volitional and automatic actions are as few as possible. The
patients will get up and dress in the morning, but they take
hours to do so. They eat their meals, keep themselves fairly
clean and tidy and perform all the necessary daily functions;
but slowness in performance is characteristic of them all.
The above is the clinical picture of an extreme case, but the
medical man should be on the alert for mild cases exhibiting
422 MIND AND ITS DISORDERS
merely, for example, depression, infrequent pulse, mental de-
pression and a malar flush.
Morbid Anatomy and Psychopathology.—The condition of the
thyroid has already been mentioned. The connective tissue
throughout the body is infiltrated with a jelly-like substance to
such an extent as to cause compression of the parenchyma of the
various organs and to interfere with their function. No changes
have, however, been discovered in the central nervous system.
From a psychological standpoint myxcedema is a very interest-
ing disease in that the psychical disabilities of the patient can
all be explained by the mechanical interference of the motor
functions. The muscle fibres being compressed by the mucinoid
substance, volitional and instinctive movements are all rendered
difficult of performance. By the same mechanism the muscular,
glandular and even vasomotor changes constituting emotional
reaction are impeded so that the patient does not experience
emotion. Similarly there is an impediment to that muscular
adjustment of the organism to facilitate the reception of sensory
impressions, which we call attention; and the difficulty of per-
ception, retardation of the association of ideas and inability
to retain new impressions may all be traced to this defect of
attention.
Although no histological changes in the nervous system have
as yet been described in association with myxcedema and
although the mental symptoms are all referable to mechanical
interference with the musculature, it is not to be supposed that
the central nervous system is unaffected by the toxin which
presumably circulates in the blood owing to the absence of the
neutralizing influence of the internal secretion of the thyroid.
On the contrary the mere fact that the natural termination of
the disease is coma is antagonistic to such a view.
Course and Prognosis.—In the absence of treatment myx-
cedema is a progressive disorder, terminating fatally. The power
of resistance of the tissues to infection is lowered, so that many
of the patients die of some intercurrent disease, especially
tuberculosis. If, however, the disease runs its course and death
is directly due to myxcedema, extreme physical weakness sets
in towards the end, the body shrinks and wastes and the patient
dies comatose. It is remarkable in such cases that the mucinoid
substance is not to be discovered in the tissues after death.
Treatment.—This consists in the administration of thyro-
iodine. It is usually given in the form of the dried thyroid
gland of the sheep. It is necessary to start with small doses
CRETINISM 423
(the equivalent of $ to I grain of the fresh gland daily) and to
work up gradually to larger quantities. The patient should
keep his bed during the first few weeks of treatment. Indica-
tions that he is receiving too large a dose of thyro-iodine are
tremor of the fingers, rise of temperature and acceleration of
the pulse-rate.
Even when all the symptoms of myxcedema have disappeared
the patient must continue to take the drug regularly for the
rest of his life in order to prevent recurrence of the disease, the
dose being kept as small as is compatible with his health.
CRETINISM.
This is a state of defective mental and physical development
due to congenital deficiency or absence of the thyroid body.
Etiology.—The disease is endemic in certain mountainous
districts on the Continent; in this country it occurs only sporadi-
cally. Where it is endemic the drinking-water is usually held
responsible, probably with reason, for the disease has been
stamped out in one or two villages by inducing the inhabitants
to substitute rain-water for drinking purposes. Analysis of the
spring-water of cretinogenous districts has shown that it usually
contains chalk, sulphide of iron and sulphate of magnesium.
There is some evidence that endemic goitre is caused by a micro-
organism, since it can be prevented by passing the water of the
locality through a Berkefeld filter before allowing it to be used
for drinking purposes; but it has not yet been ascertained whether
endemic cretinism can be prevented in the same way. The cause
of sporadic cretinism remains to be discovered. The disease is
slightly more frequent in girls than in boys.
Physical Signs.—The first signs of cretinism are seldom observed
before the sixth month, sometimes not until the child has attained
the age of two years, or even later. It is then noticed that
growth is retarded or irregular, the body not keeping pace with
the head, that the voice is hoarse, low-pitched and unnatural,
the skin harsh and dry and the abdomen unduly prominent.
Examination of the thyroid region reveals either absence of the
gland or the presence of a small goitre.
If the disease be left untreated, the body remains stunted in
growth and the infantile condition persists, so that a cretin of
twenty years of age may look like a child of four. The cretin
differs, however, from a normal infant in presenting many
deformities.
424 MIND AND ITS DISORDERS
The head is too large for the body and the spinal muscles are
too weak to hold it up, so that the chin is liable to sink on the
chest. As a result the shoulders become rounded and there is
compensatory lordosis in the lumbar region, the aspect of which
is enhanced by the swollen belly. The limbs are short and the
tibiz may curve outwards as in rickets. The hands and fingers
Fics. 66 AND 67.—M. B., &T. 16 YEARS. SPORADIC CASE OF CRETINISM
FROM BERKSHIRE.
are stubby and the ligaments lax, so that the fingers can be
bent backwards to a right angle.
The head is elongated and, especially in the occipital region,
broad. On the top it is flat. There is undue separation between
the eyes.
The integuments are swollen and look cedematous > Duteas
in myxcedema, they do not pit on pressure nor is there any
exudation of serum when the skin is punctured. The face
CRETINISM A25
and nose are broad and puffy, the lips thick and the eyelids
swollen. These features taken in conjunction with the swollen
abdomen and the podgy limbs give the child a very characteristic
appearance.
The swelling also affects the mucous membranes. The tongue
is swollen, often projecting between the incisor teeth; and there
is swelling of the soft palate and laryngeal tissues as in myX-
cedema.
Soft lobulated lipomata, each about the size of a hen’s egg,
are to be felt in the supra-clavicular regions and less frequently
in the axillz.
The temperature is subnormal and the pulse-rate slightly
increased. Examination of the blood reveals a diminished
number of the red corpuscles and diminution of hamoglobin.
The leucocytes are also fewer than normal.
Dentition is late and the teeth are very liable to become
carious. The sexual apparatus and the genital functions develop
late or not at all.
Mental Symptoms.—Intellectual deficiency which in many
cases amounts to an extreme form of idiocy is characteristic of
this condition.
Three grades are recognized:
1. Cretins in whom mental activity is at the very lowest
ebb, who are in a perpetual state of somnolence, who utter no
articulate sounds and whose sole evidence of mentation is the
emission of strident cries of satisfaction or dissent when food 1s
given or not given to them;
2. Semi-cretins who are able to walk a few paces slowly and
with difficulty, to speak a few words and to learn how to perform
a few simple acts; and
3. Cretinoids whose mental development is less retarded than
that of the semi-cretins; these are to be regarded as imbeciles
rather than idiots.
The mental condition associated with cretinism differs little
from other forms of idiocy and imbecility. The cretin is perhaps
of a gentler disposition; he possesses fewer criminal instincts
and his movements are slower than those of other feeble-minded
children.
Morbid Anatomy and Pathology.—As in myxcedema, all the
tissues are infiltrated with mucinoid products and the thyroid
is absent, diminutive or goitrous. The shape of the skull was
ascribed by Virchow to premature synostosis between the basilar
portions of the sphenoid and occipital bones. The sella turcica
426 MIND AND ITS DISORDERS
is small, the clivus steep and the foramen magnum smaller than
natural.
Macroscopically the nervous system appears to be fairly
normal. Under the microscope the cortical nerve-cells are seen
to be slightly smaller than the normal and they tend to be globose
as in other forms of idiocy.
Prognosis.—In cases of pure cretinism, not cretinism plus
genetous idiocy, the prognosis is favourable if treatment is begun
early, before the child is three years of age. Physical improve-
ment can be accomplished at any time of life by the administra-
tion of thyroid, but the longer treatment is delayed the smaller
is the amount of intellectual improvement to be expected.
Treatment.—The patient should be removed to a healthy
neighbourhood or at least to a district where the drinking-
water is pure and iron-free. Dried thyroid should be adminis-
tered as in myxcedema. The equivalent of not more than
10 grains of the fresh gland per week may be given at first and
this dose may be gradually increased until at the end of six
months the patient is taking the equivalent of Io or I5 grains
daily. This latter dose must be continued during the remainder
of the patient’s life if relapse is to be avoided. Under this
régime the patient grows rapidly (about 4 inches a year at
first), the swelling of the integuments and the supraclavicular
lipomata disappear, the skin tightens and gets soft and supple,
the temperature rises to normal, the blood becomes normal
and the child active and intelligent. During the rapid growth
the legs are liable to become bowed, owing to the cartilage
of the long bones growing faster than the ossifying portions.
To prevent this deformity it may be desirable that some form
of apparatus be worn for the purpose of giving lateral support
to the legs until the greater part of the epiphyseal cartilages has
become ossified.
THE PiTuITARY Bopy.
An extensive study of this organ during recent years, especially
by Cushing, has revealed that it consists of two entirely dis-
similar parts possessing separate functions, the anterior half
affecting the growth of the organism and the posterior controlling
its carbohydrate metabolism. Either or both of these may be
hypertrophied or more or less destroyed by disease (atrophy,
sclerosis or tumour) and consequently there is a considerable
variety of clinical pictures arising from pituitary affections,
THE PITUITARY 427
according to the degree or manner in which the anterior and
posterior lobes are involved.
Disease or atrophy of the anterior portion results in asthenia,
chilliness, excessive thirst with polyuria, adiposis of the femi-
nine type perhaps with pendulous breasts, enlargement of the
pelvis which is similar in type to that of the female, atrophy of
the testes, epididymes and spermatic cords, absence of pubic and
axillary hair (infantilism) and a pale, waxy, wrinkled face.
Mentally these patients are dull, apathetic or depressed, and
intellectually stupid. In some patients there is definite con-
fusion with imperception, disorientation and failure of memory.
They are lacking in energy and initiative in conduct and con-
versation and their speech is somewhat drawling. Drs. Prior
and Evan Jones of New South Wales have found cases of this
type among their epileptic patients.
Hypertrophy of the anterior portion during early life causes
gigantism or precocious development, especially in respect of
the growth of hair about the face, pubes and axille and of
the genitalia. In later life this hypertrophy gives rise to
acromegaly.
Mentally, so far as I am aware, these patients are unaffected.
Disease or atrophy of the posterior portion is mainly character-
ized by an abnormal tolerance of sugar. Some of these patients
can take as much as 300 grammes daily without rendering the
urine capable of reducing Fehling’s solution.
The mental symptoms in such cases are usually of the con-
fusional type: imperception, hallucinations (especially of vision),
disorientation, failure of memory, lack of voluntary attention
and a general clouding of consciousness.
Hypertrophy of the posterior portion gives rise to an alimentary
glycosuria, by which is meant that the glycosuria occurs after the
ingestion of food. The affection does not appear to be associated
with mental disorder.
In short, it would seem that mental disorder arises only from
destruction or atrophy of the pituitary body, not from its hyper-
trophy. When confusional symptoms arise they probably in-
dicate some affection of the posterior lobe; but it is likely that
both anterior and posterior hypopituitary mental symptoms
are of toxic origin. The depression associated with anterior
hypopituitarism cannot be ascribed to changes in the blood-
pressure because the substance which raises the blood-pressure
is derived from the posterior part only (from the pars intermedia
originally).
428 MIND AND ITS DISORDERS
Treatment.—Specific treatment consists of giving pituitary
extract of which the organism stands in need (the anterior and
posterior extracts can be obtained separately, as required); but
it is found in many cases that thyro-iodine, thyro-glandin or
some such preparation has a more gratifying result clinically
than pituitary preparations. In this connection the intimate
physiological relationship between the thyroid and pituitary will
naturally occur to the reader.
Apart from specific treatment the various mental symptoms
can be dealt with as they arise, on general medical principles.
THE SUPRARENALS.
Most patients suffering from Addison’s disease are free from
mental symptoms except during a terminal delirium, sometimes
accompanied by convulsions.
In rare cases, usually running a chronic course, the patients
are liable to attacks of depression with lack of initiative, dis-
tractibility and excessive emotionalism (flow of tears etc.).
Gallais* has reported the case of a patient suffering from
Addison’s disease of twenty years’ standing, who suffered from
mental attacks of this kind accompanied by auditory hallu-
cinations and delusions of persecution, this state alternating
with attacks of furious maniacal excitement, logorrhcea, euphoria
and motor agitation. The change from depression to excite-
ment was invariably accompanied by a rise of blood-pressure.
The observation may be important because Craig, in his study
of the blood-pressure in maniacal-depressive insanity, found it
to be high in melancholia and low in mania.
In view of the observation mentioned on page 368, it seems
probable that the suprarenals may have an important relation-
ship with epilepsy.
Treatment.—The symptoms are invariably relieved by the
administration of adrenalin.
THE PINEAL.
Tumours destroying this body, which are of rare occurrence,
usually occur in childhood and then give rise to premature
development of the sexual organs and characters, at any rate
in the male. In association with this physical peculiarity the
patients are sometimes, perhaps usually, precocious in their
mental evolution. On the other hand, the tumour may either
* Rev. Neurologique, 19tt.
ENDOCRINAL INSANITIES 429
retard mental development by obstructing the flow of cerebro-
spinal fluid through the iter, thus causing hydrocephalus (q.v.),
or induce mental hebetude in the same way as any other intra-
cranial tumour.
THE SEX GLANDS.
The physical and mental results of castration and oophcrec-
tomy, generally infantilism with an approximation of the
patient’s characteristics to those of the opposite sex, are con-
sidered to be so well known that they are taken for granted;
so much so that I am not aware of a single paper systematically
recording the results of scientific observation in these cases.
After recent oophorectomy there is sometimes a short attack
of depression scarcely distinguishable from true melancholia
and most physicians for mental disease have had psychotic
patients whose ovaries had been removed some years previously ;
but, so far as I am aware, there has been no collective investi-
gation of these cases to determine whether the mental disorder
is directly due to lack of the ovarian endocrine.
Pages 319 and 340 should here be read again in view of a
possible relationship between dementia preecox and atrophy of
the sex glands.
THE PARATHYROIDS, THYMUS, PANCREAS ETC.
So far as our knowledge goes there is no specific mental
disorder associated with disease of these bodies; but clinical
study of this group of organs is yet in its infancy respecting
their mental as well as their physical activities.
ORGANIC INSANITIES.
THESE result directly from organic disease of the brain, which
may be either partial destruction of the organ (for example,
from thrombosis of the middle cerebral artery of one side), in-
flammation of the cerebrum or the meninges or widespread
degenerate changes.
It is remarkable that the commonest destructive lesions, such
as the above-mentioned which causes ordinary hemiplegia, give
rise to comparatively little mental disturbance. The obliteration
of projection areas has but little effect on mentation; but destruc-
tion of those parts of the cerebrum which contain fibres essential
to the association of ideas (association-fibres) naturally causes
some degree of dementia, which may be considerable, varying
with the site and size of the lesion.
On the other hand, widespread microscopic degenerative
changes may induce the most profound and complicated mental
disorder because, during even the earlier stages of such maladies,
there is extensive interference of function but little destruction.
The psychical result of such interference is the escape of normal
complexes from vepression so that they find éxpression, usually
in the distorted form of bizarre symptoms. This is a point
which requires emphasizing, viz., that the psychical mechanism
underlying these insanities is the same as that underlying other
mental disorders, the only difference being that the bonds of
repression are burst because they are weakened by organic
disease and not merely on account of the irresistible force of
the escaping complex.
These remarks especially apply to the first disorder described
under this group; but—by way of elucidation—let us momen-
tarily revert to the subject of alcoholism. In the earlier stages
a man seeks relief from his unrecognized conflict by indulgence
in alcohol for various unconscious reasons; but alcohol in large
quantities induces physical degeneration of the cortical neurons
and therefore of the mental repressing forces. The repressing
forces being weakened, this time through physical degeneration
of the nervous system, the patient is obliged to take more and
aS,
GENERAL PARALYSIS A3I
more doses of alcohol to relieve the mental conflict, not only
because the unrecognized complex is forcibly striving for ex-
pression, but also because the repressing forces are organically
weakened.
CHAPTER-XVII-
GENERAL PARALYSIS (DEMENTIA PARALYTICA).
GENERAL PARALYSIS is an organic disease of the cerebral cortex
usually occurring in the fourth decade of life, possessing a large
array of clinical symptoms, leading to progressive motor para-
lysis and profound mental deterioration, and terminating fatally,
with very few exceptions, in two or three years. For some
reason or other it is less prevalent than it used to be. According
to the statistics of the Board of Control, it was responsible from
1878 to 1914 for 7-6 per cent. of the admissions to asylums, the
lowest being 6-I per cent. in 1902; but during the years 1920-
1922 it accounted for only 5-7 per cent. The reason for this is
unknown, and it has been stated definitely that the salvarsan
treatment of syphilis is not responsible for the change.
Etiology.—In previous editions an overwhelming mass of
evidence was given in support of the hypothesis that general
paralysis was a sequel to syphilis. This is no longer necessary
since Noguchi demonstrated the presence of spirochetes in
the cerebral cortex of patients who had died from the disease.
This observation has been confirmed by many neuropathologists
and, I believe, refuted by none. Moreover, it is now generally
accepted that the Wassermann reaction is nearly always positive
in the cerebro-spinal fluid and also, though not quite so fre-
quently, in the blood. The reaction tends to disappear as the
disease progresses. When a negative result is obtained in an
early case, the positive reaction is almost sure to occur at some
subsequent examination, perhaps a few weeks later.
General paralysis usually develops about ten years after
syphilitic infection; it is usually, therefore, a disease of the
fourth decade. I have, however, seen cases occurring as early
as two years and as late as thirty-two years after infection, the
disease appearing in this last patient at sixty-three years of age.
““ Juvenile ’’ cases occur as a sequel to congenital syphilis, the
_ earliest case I have seen being in a child of seven. On the other
hand, general paralysis due to congenital syphilis may develop
as late as twenty-eight years of age.
432 MIND AND ITS DISORDERS
Adult general paralysis occurs in the pauper class four times
as frequently in men as in women, and in the private class fifteen
times as frequently. This difference between the two classes is
what we should expect on the supposition that syphilis is the
cause of general paralysis, in view of their different social customs.
We may correlate the pauper statistics with the statement from
Denmark, where syphilis is a notifiable disease, that syphilis
occurs four times as frequently in men as in women.
Adolescent and juvenile general paralysis occur with almost
equal frequency in males and females, females preponderating
to a slight extent. This also is what would be expected of a
malady due to congenital syphilis. Males and females are
equally exposed to the inheritance of syphilis; general paralysis
would therefore be expected to be equally distributed between
the sexes in the juvenile and adolescent cases, with a slight
preponderance of females as in the general population.
The professions are represented among general paralytics in
proportions which are in accordance with the syphilitic origin
of the disease. For example, one-third of Hirschl’s cases and
two-thirds of Garbini’s cases belonged to the labouring class,
go per cent. of Krafft-Ebing’s cases were officers in the army,
while Hirsch] had only one Roman Catholic priest among his
200 general paralytics and Krafft-Ebing had no such instance
among his 2,000 cases. Salaris stated that there was only one
case occurring in Sardinia during the years 1891-1897 in a priest,
and that priest had certainly had syphilis. Bouchard also
demonstrated the infrequency of general paralysis among the
clergy.
The geographical and racial distribution of general paralysis -
are of considerable interest.. In Macpherson’s “‘ Mental Affec-
tions ’’ the author remarks: “It may be generally stated that
the disease does not exist in the Highlands of Scotland or in
Ireland outside the larger cities, or in the more rural and remote
districts of Wales and the South of England. It reaches its
maximum in the busy manufacturing towns of the Midlands,
and in the larger cities of the United Kingdom.” Similar
remarks apply to Sweden. The author continues: “‘ Taking a
wider geographical area, it is present in the countries of Western
Europe and North America, and is practically unknown among
the uncivilized nations of the world !”’
In Germany general paralysis has invaded the more rural
districts to a greater extent than formerly; but this can be
accounted for by the military organization which exists there,
GENERAL PARALYSIS AND SYPHILIS 433
whereby every man is exposed in his youth to barrack-room life
and syphilization.
This distribution of general paralysis corresponds fairly well
with the distribution of syphilis; the latter disease, however, is
rather more widely spread and there are some special countries
which demand closer investigation.
Until the last decade both syphilis and general paralysis were
rare diseases in Iceland, but now syphilis may be regarded as
endemic there and by no means uncommon. General paralysis
is, however, still rare and, curiously enough, the pathologists at
Reykjavik (the capital of the island) are remarkably insistent
that repeated investigations of these cases yield decidedly
negative results respecting their syphilitic origin. Similarly,
syphilis is rife in China, Japan, and the Mohammedan
countries, while general paralysis is said to be comparatively
rare.
Basing. conclusions upon the racial distribution it has often
been argued that general paralysis is essentially a disease of
civilization.
It is noteworthy that only about 3 per cent. of syphilitics
develop general paralysis, and I think that this fact has been
adequately explained by Mott. In a paper in the British
Medical Journal of January 4, 1908, he brought forward striking
evidence’ that there may be a special neurotoxic variety of the
Spirochata pallida or Treponema pallidum—in other words,
there is probably a special general-paralysis-producing variety
of syphilis.
In view of the fact that ordinary syphilitic manifestations
(irites, gummata etc.) are extraordinarily rare in patients suffer-
ing from general paralysis I suggest, in amplification of Mott’s
observations, that the spirochete of general paralysis (and tabes
dorsalis) is specific and that, in spite of its biological resemblances
to that of syphilis, the two are not identical. According to this
view general paralysis is a specific (venereal) disease and general
paralytics who exhibit the ordinary manifestations of true
syphilis must be regarded as patients who have contracted two
separate specific diseases, possibly at the same time, viz., general
paralysis and syphilis.
It is remarkable, in view of our conclusions, that there is no
record of any asylum pathologist or attendant on the insane
having contracted general paralysis from one. of his patients.
The observation is gratifying, but the fact is rather difficult to
explain.
28
434 MIND AND ITS DISORDERS
Physical Signs.—Although tertiary manifestations of syphilis
are of rare occurrence in general paralysis, tabes dorsalis, which
has also been regarded as a late sequel to syphilis, is recognizable
clinically in about 25 per cent. of the cases, and some degeneration
of the posterior columns can be discovered post mortem in nearly
every case.
It is found clinically that tabes associated with general
paralysis is seldom very advanced and the diagnosis, as a rule,
depends merely on the association of absence of knee-jerks
with loss of the pupillary light reflexes. Anesthesia, lightning
pains and extreme inco-ordination are exceptional.
Epileptic and epileptiform (Jacksonian) convulsions and so-
called apoplectiform attacks are manifestations liable to occur at
any time in the course of the disease; they may be the initial
symptom calling attention to the patient’s condition or they
may be the concluding event determining the fatal issue. They
are, however, most common in the second stage.
Epileptic fits occurring in the course of general paralysis are in
no way distinguishable from those seen in idiopathic epilepsy.
Batches of fits are not infrequent, giving rise to a true status
epilepticus. Isolated fits occur in all degrees of severity and I
have seen attacks indistinguishable from minor epilepsy followed
by typical post-epileptic automatism.
Similarly local fits without loss of consciousness, in no way
distinguishable from the Jacksonian convulsions seen in cases of
subcortical tumour, are liable to occur in general paralysis.
Naturally enough, they begin most frequently in the thumb
and forefinger of the right hand, opposition of the thumb being
the most recently evolved, most voluntary, and therefore most
unstable motor function of the cortex. The convulsion travels
up the arm, usually as far as the shoulder, and leaves the limb
paralyzed for some hours or days after the attack.
In an apoplectiform attack similar local paralysis occurs without
previous convulsion and, in like manner, passes off within a few
days. Such an attack is usually associated with disturbance
of consciousness, varying in degree from mere somnolence and
confusion to a condition resembling true apoplexy with coma
and stertorous breathing. As consciousness is restored, it is
found that the patient is suffering from hemiplegia or brachial
monoplegia (both are usually on the right side), accompanied
perhaps by motor aphasia and apraxia. Sensory and motor
aphasia may also occur independently of other paralyses. All.
these paralyses pass away in the course of a few days or weeks.
PHYSICAL SIGNS OF GENERAL PARALYSIS 435
Closely allied to these are attacks of fever in which the patient’s
temperature rises above 100° F., perhaps to 104° F., no visceral
or other lesion being discoverable to account for the rise. It
has therefore been ascribed to disturbance of the heat-regulating
centres, especially of the vasomotor centre, since the attacks are
frequently accompanied by pallor or, more often, by flushing
and swelling of the face.
The so-called automatic movements of general paralysis may
be most appropriately mentioned in this place, since they are to
be regarded as more or less of the nature of a chronic convul-
sion. They are imstinctive rather than automatic and consist
of constant involuntary movements, usually about the mouth,
movements of sucking, chewing, smacking the lips, tasting,
deglutition and grinding of the teeth. Picking of the nails also
occurs with some frequency.
Perhaps the commonest and most characteristic motor dis-
turbance is tremor, especially about the face, tongue and hands.
The lower part of the face is most affected, in contradistinction
to alcoholic tremor which affects mostly the upper part of the
face. If the patient be asked to show his teeth, the upper lip
is seen to be tremulous owing to weakness of the levators and
zygomatics.
The lingual tremor is best seen when the patient is directed to
protrude his tongue slowly. Characteristically it is an antero-
posterior tremor, so-called trombone movement, not a rippling
on the surface of the tongue as in alcoholism. I have several
times observed tremor of the uvula in general paralysis.
Hand tremor is best elicited by getting the patient to extend and
separate the fingers, the wrist being extended at the same time.
Weakness of the lower limbs sets in as the disease advances.
The gait becomes at first shuffling like that of an old man, the
patient scarcely raising his feet from the ground, so that he is
liable to stumble over slight obstacles. Later the gait becomes
tottering and finally the patient has to be kept in bed to avoid
falls. Here contracture of the flexor muscles sets in and pro-
gresses until the patient’s knees are almost up to his chin.
The muscles waste, especially the interossei and the muscles
of the thenar and hypothenar eminences, and Lenzi has found
on electrical examination in some cases kathodal closure con-
traction equal to anodal closure contraction.
The commonest pupillary change in general paralysis is slug-
gishness, diminution or absence of the reflex to light on both
sides. This is one of the cardinal signs of the disease; but I have
436 MIND AND ITS DISORDERS
met with several cases in which the disease ran its course without
loss of reaction to light at any stage. Marandon de Montyel,
however, who made a careful examination of the pupil reflex in
140 general paralytics from the onset of the disease to the death
of the patient, states that in no case did he find the pupils normal
from beginning to end. He found in some cases exaggeration of
the reflex in the initial phase, and that this was always succeeded ~
by diminution; but I have been unable to confirm this observa-
tion. Consensual pupillary reaction, contraction when light is
thrown into the opposite eye, may be abolished before, simul-
taneously with or subsequently to loss of the direct reflex.
Dr. Bevan Lewis considered loss of the sympathetic reflex to
be the earliest pupillary sign of general paralysis (dilatation on
pinching the skin of the neck).
In some cases loss of the light reflex is coupled with loss or
diminution of the pupillary contraction associated with con-
vergence (often called erroneously the “‘ reaction to accom-
modation ’’). This sign is occasionally unilateral, with the result
that the pupils are markedly unequal in diameter, the difference
being often as much as, or even more than, 2 millimetres.
Occasionally the pupils are eccentric, of irregular outline
or oval. Pilcz, Marina and others have shown that these
phenomena are due to disease of the ciliary ganglia.
Nystagmus and, in the tabetic cases, ptosis are sometimes
observed.
There is almost always some contraction of the visual field
in general paralysis. Optic atrophy, although fairly frequent,
is usually slight; but it may be complete in some tabetic cases.
I have seen one (atypical) case of complete optic atrophy in
general paralysis with exaggerated knee-jerks. In 1881 he had
forty-three boils on his body (? syphilis) ; in 1882 loss of memory
and difficulty of articulation which cleared up in six weeks;
in 1888 he gradually lost the sight of his right eye, and in 1894
he was admitted to Bethlem with general paralysis, complete
optic atrophy in the right eye and partial atrophy, which in-
creased under observation, in the left. He died of the disease
in 18096.
Kéravel and Raviart state that sclerosis of the optic nerve
in tabes is insular, but in general paralysis annular. In the
author’s experience there is this clinical difference—that in tabes
the physiological cup tends to be filled in more than in general
paralysis. A slight amount of swelling of the disc (4 to 1 diopter)
may occur in the early stages of the disease.
CEREBRO-SPINAL FLUID 437
In depressed cases the superficial reflexes are commonly
diminished or absent, especially the scapular, epigastric, ab-
dominal, cremasteric and gluteal. Stroking the sole of the foot
almost invariably elicits a flexor response (except after a seizure) ;
but I have seen an extensor response in four cases. The pharyn-
geal reflex is almost always abolished, frequently in the earlier
stages of the disease, invariably in the latter.
The tendon reflexes are abolished in the tabetic patients
(about 25 per cent.), exaggerated in the remainder. This
exaggeration is well marked in both upper and lower limbs.
Ankle-clonus does not occur in uncomplicated cases. The
exaggeration of the knee-jerk is almost characteristic in that the
excursion of the foot is large, the anterior movement lively, but
the return (semimembranosus action) sluggish. As a result, the
knee-jerk has a “ floppy ’’ aspect. This exaggeration of the knee-
jerk becomes less marked as the disease advances.
Malnutrition of the skin is evidenced by the furrowed nails
and “‘ glossy skin ’’ frequently seen in the hand and feet. Bed-
sores are liable to occur at points of pressure, especially over
the sacrum, buttocks and trochanters; mainly because the
patients lose control, first of the bladder, then of the rectum,
in the terminal stages of the disease.
Frequently retention of urine is an early symptom demanding
the passage of a catheter. There is an increase in the quantity
of urine passed during the twenty-four hours. In other cases
the urine dribbles away from a full bladder, apparently owing
to relaxation of the sphincter vesice.
Signs of arterial degeneration may be observed in some cases,
a distinct jog being noticeable in listening over the first part of
the aorta with a wooden stethoscope (dilated aorta). The blood-
pressure is usually raised.
The cerebro-spinal fluid is characterized by:
(a) Leucocytosis, the presence of plasma cells being pathogno-
monic of general paralysis (Fig. 69) ;
(b) Excess of globulin, instead of the normal infinitesimally
small amount;
(c) A positive Wassermann reaction in the majority of cases
or, as some observers state, in all cases of general paralysis;
(2) Increased pressure, which causes it to spurt out almost like
a stream of urine when a lumbar puncture is made.* )
Mental Symptoms.—General paralysis is a disease tending to
the progressive destruction of the whole nervous system. Accord-
* For further details see Appendix B.
438 MIND AND ITS DISORDERS ©
ingly we find that the earliest symptoms of the disease consist
of deterioration of those functions of the nervous system which
were the latest to be acquired. The patient’s accomplishments
are not up to their former standard of excellence, the business
man fails to drive a bargain with his former success, the artist’s
pictures lack their earlier vigour and the musician’s performances
receive no encore as of old. It is usually said that the memory
for recent events and proper names is faulty, but the ordinary ~
systematic examination usually fails to confirm this statement.
The failure of memory is of another order; the patient forgets
resolutions. He forgets to post letters, to catch a train, to
keep an appointment or to take his keys with him, perhaps
leaving them dangling from the lock of his safe. Dr. Mercier
has humorously called this symptom “ loss of memory for future
events’. In the later stages of the disease the general paralytic
becomes incapable of recognizing friends and relations.
Apart from the tabetic cases, there is frequently in the early
stages some loss of cutaneous sensation ; but in the most advanced
stages the patient responds to a pin-prick in any part of the body.
It must be admitted, however, that there is no means of ascertain-
ing whether the response is purely reflex or dependent on cortical
activity. Hyperzsthesia occurs in some of the excited cases.
Attention has been directed to anesthesia of the ulnar nerve
in general paralysis, the “‘ funny-bone ”’ sensation being absent
when the nerve is nipped on the inner side of the elbow. In
the author’s experience, this symptom occurs in less than half
the cases; moreover, it is present in a considerable number of
normal people.
The olfactory sense is frequently lost on one or both sides
(anosmia) and there is often diminution of the sense of taste
(ageusia), especially for salt. The sense of hearing is almost
invariably diminished in the late stages, sometimes in the earlier
stages of the disease; but there appears to be no limitation of
the range of hearing, the high notes of a Galton’s whistle being
heard as well as formerly, if they are loud enough.
Hallucinations of vision or of hearing occur in about 25 per
cent. of the cases, but they seldom form a prominent feature in
the clinical picture. Perception remains fairly good as a rule
until the later stages of the disease, when the patient gradually
becomes more and more oblivious of his surroundings and
incapable of apprehending their nature (imperception). The
appreciation of time and space necessarily disappears pari passu
with ideation and perception.
GENERAL PARALYTIC DELUSIONS 439
Judgment and reasoning are impaired almost from the first
and delusion is the rule. In the classical form of the disease
the delusions are expansive in nature. The patient believes
himself to be possessed of wealth beyond the dreams of avarice;
his treasures are to be measured, not by millions, but by ship-
loads and his estates comprise gold-mines and continents. He
is a mile high and weighs tons. He is King, Emperor, nay,
God Himself. He can slay his millions or raise the dead at
will. He can play a hundred instruments and speak a thousand
tongues; but, on being asked to give an example of any one of
these, he will break into an unintelligible jargon. He will tell
you that he is the champion runner for all distances and, being
asked his time for the hundred yards, display utter ignorance
of athletics by answering “‘ Three minutes ’’.
Although the classical type of delusion in general paralysis
is of the expansive variety, fancies of this nature appear to be
nowadays less common than in former years. Melancholiac and
hypochondriacal delusions are now more frequently encountered.
In their characteristic form, however, they still retain an element
of expansiveness. The patient believes that he owes millions to
the King, that he is the King himself and cannot bear the weight
of such responsibility, or that he has been suffering for thousands
of years. Other delusions are more hypochondriacal in char-
acter; there are tons of faeces in the abdomen, gallons of treacle
in his chest, a harp in his throat, or his brain is too big for his
skull. This curious mixture of depression and exaltation,
melancholiac megalomania, is peculiar to general paralysis.
Delusions of persecution are not uncommon. When they
occur they lack the systematization characteristic of paranoia.
The defect of reasoning power is well illustrated by a symptom
first described, I believe, by Joffroy. Very shortly after the
onset of the disease the patient is unable to do simple arithmetical
sums on paper. He adds or multiplies from left to right; or
perhaps in multiplying, say, 35 by 5, he will say, “ Five fives are
twenty-five ’’ and put down 25 on the answer line, the ultimate
appearance of the sum being:
35
#
1525
In some cases the patient gives up the attempt without putting
pen to paper.
440 MIND AND ITS DISORDERS
The most striking changes take place in the domain of action
or conduct. One by one, the patient loses control of his instincts.
He ceases to attend to business, spends money recklessly and
occupies the whole of his time out of doors playing games or
motoring. Then he loses control of the sexual instinct, exposes
himself or commits some indecent assault whereby he falls into
the hands of the police. He makes absurd collections, sets to
work to buy up all the grandfather clocks in London or buys a
gramophone with thousands of valuable records: all the while
he can afford none of these things. At this stage his friends
begin to realize the true state of affairs and place him in an
asylum or at least in such conditions as will put an end to his
extravagance; but the collecting instinct continues—he hoards
up all sorts of rubbish, old newspapers, worthless pebbles, buttons,
odd playing-cards and chessmen.
He becomes conceited, boastful and ambitious like a boy of
fifteen, differing, however, from the latter in that he develops
delusions of exaltation with regard to his prowess, capabilities,
health, wealth and position.
The eating instinct gets out of hand: he eats ravenously, even
when he has only just completed a meal, and bolts potatoes
and slices of meat whole. It is on account of this symptom
that general paralytics in institutions for the insane are sys-
tematically fed on mince.
By this time the patient’s circumstances are usually such
that the constructive instinct is not allowed full play; but he
will often paint pictures which are surprisingly good considering
that he has never put brush to paper before (thus demonstrating
the advantage of self-confidence), or he may make attempts,
usually not so good, to write music. He is full of schemes for
benefiting humanity. He would make eggs from old oyster-
shells, warm the poles by a system of hot-water pipes, tunnel
the earth to Australia or take personally conducted tours round
the planets.
Then he becomes destructive, tears up his clothing or smashes
windows or such articles of furniture as vases and flower-pots.
Practical joking is not an uncommon feature about this stage.
There is sometimes a transient return of the childish instinct
of make-believe. For example, the patient will say that he is
a Spanish onion, a poached egg or a pat of butter; not that he
believes such absurdities, but merely in the playful spirit of
make-believe.
Before the general paralytic has lost control of these early
INSTINCTS IN GENERAL PARALYSIS 441
instincts degeneration of those more lately acquired has already
begun. The out-of-door instinct has gone; he has no desire for
hunting, fishing, shooting, motoring or out-of-door games. Simi-
larly his sexual instinct disappears. He ceases to collect rubbish,
or anything else for that matter. His boastfulness and conceit
vanish and he forgets former delusions. He no longer evolves
schemes, he becomes less destructive, loses the instinct of clean-
liness, and is wet and dirty.
The instincts to walk, stand and sit up disappear in turn and
the patient reverts to the infantile age at which he crawled on
all-fours.
As with the instincts, so with the emotions. During the
earlier stages of the disease the patient is excessively emotional;
he laughs or weeps at nothing and a sympathetic word suffices
to evoke a flood of tears. At other times he flies into a passion
of anger without any adequate cause. In the latter stages, on
the other hand, emotion disappears to such an extent that even
the normal expression of the man’s face, largely dependent on
the naso-labial furrows, is obliterated.
Speech is markedly disturbed from the first. The vocabulary
becomes more and more limited, proper names being the first
to go, then common nouns, adjectives, verbs and interjections.
Interjections are the last parts of speech to be lost and of these,
“yes”’ and “no” are the very last. The first volitional word
of the infant, “yes” is the last word uttered by the general
paralytic, should the disease run its complete course without
being cut short by some fatal intercurrent illness.
Incoherence occurs in the majority of cases during some
period of the disease. In some cases it is owing to the flight of
ideas being too rapid for the patient’s language to keep pace
with them; in others it is due to mental confusion.
As a rule, the speech is slow, hesitating and often stammering.
The patient has difficulty in finding the word he requires. The
continuity of a sentence is frequently cut short by his forgetting
the subject of his discourse and the most trivial interruption
serves to produce such a result. It is due to an apprehension
of this failing that some general paralytics exhibit a form of
mutism, voluntary aphasia, from time to time.
Defect of articulation, although a physical rather than a
psychical symptom, is best considered in this place. The general
difficulty of articulation leads to stuttering and the elision or
repetition of syllables and words. On account of tremor and
loss of control of the muscles of articulation the consonants are
442 MIND AND ITS DISORDERS
blurred and uttered in a quivering manner. Various phrases,
some of which are unnecessarily difficult, have been devised as
special tests for the articulation of general paralytics. The
following are a few examples:
‘“ Around the rugged rock the ragged rascal ran his truly rural
race.”
“ The Irish constabulary extinguished the conflagration.”
““ She stood at the door of Burgess’s fish-sauce shop, welcoming
him in.”
“She sells sea-shells and shaving soap.”’
“ Biblical commentators.”
“Trish artillery.’’ ‘‘ Statistical tables.’ “ Irretrievable.”’
“ Conservative.”’ “‘ British Constitution.”’
Some of these sentences are also memory tests, for the patient
is often found to be incapable of remembering the whole of one
of the longer sentences.
In reading aloud, the general paralytic omits some words,
interpolates others and modifies yet others to a slight extent, so
that the writer’s meaning is misinterpreted.
Written language suffers in much the same way. Letters and
words are elided or reduplicated. The patient becomes confused
in the construction of long sentences and seldom attempts, for
example, a dependent sentence with a possessive pronoun. As
a result, all his correspondence consists of short sentences, then
disjointed phrases, and lastly, disjointed words.
In writing to dictation he omits words, interpolates others
which are not dictated to him and modifies others in much the
same Way as in reading aloud.
The calligraphy becomes puerile: the lines are not straight, but
undulating; the individual letters are separated from one another
and occasionally show evidence of hand tremor. As the disease
advances the writing becomes larger so that a dozen words suffice
to fill a sheet of notepaper, apart from smudges and blots, which
are an invariable accompaniment.
After a short preliminary period of insomnia during the early
stages the patient is liable to fall asleep at all hours of the day,
even while he is in the midst of a most important piece of busi-
ness, and he sleeps heavily at night. As the disease advances,
persistent motor restlessness becomes a prominent symptom
during the day and he again sleeps badly at night. This
insomnia persists until the later stages, when sleep once more
becomes excessive.
The general paralytic is a very suggestible individual, and as a
STAGES OF GENERAL PARALYSIS 443
rule is easily managed, especially by strangers. His volition is
so weak that with tactful management one can always lead or
thwart him.
Stages.—Apart from the prodromal stage, in which the patient
suffers from occasional headaches, tinnitus aurium, formications,
(FE
Southark, Loni.
moet |
ket
J shawhee Dikicypls erme
» Lote wih me Lu Loni
€ ? : ~
Fic. 68.—LETTER BY A GENERAL PARALYTIC.
Joffroy’s symptom is illustrated in the last few lines. The patient was
formerly a learned scientist.
local flushings and pallors, lapses of memory and partial in-
capacity for business matters, general paralysis is usually divided
into three stages, which cannot, however, be sharply distinguished
from one another.
444 MIND AND ITS DISORDERS
During the first stage the patient loses flesh, looks ill and the
various physical signs characteristic of the disease become estab-
lished. Mentally, this stage is characterized by progressive loss
of will-power, loss of control of the instincts in the order already
described, emotionalism, inability to keep voluntary attention
fixed on a subject, and tendency to the formation of delusions.
The patient is absent-minded and forgetful of duties, appoint-
ments and even meals; but he stands the ordinary memory tests
fairly well. During the first half of this stage he is liable to be
excessively drowsy; in the latter half insomnia is the rule.
During the second stage the patient becomes unhealthily fat,
plethoric and bloated. The naso-labial folds disappear, the face
becomes expressionless and the various physical signs well
marked, especially difficulty of articulation. The beginning of
this stage is marked by deterioration of the latest acquired
instincts, the other instincts being subsequently lost. Of active
attention there is none, and now instinctive attention gradually
disappears. There is no tendency to the formation of new
delusions and former delusions become forgotten. The memory
will no longer stand the ordinary tests, and little by little, it
becomes obliterated. Sleep becomes again excessive, especially
during the day. It is during this stage that fits are especially
liable to occur. The second stage of the disease has accordingly
been called the “ fat, fatuous and fitty ” stage.
Paralysis of the limbs now sets in and the patient enters the
third stage. He is bedridden, wet, dirty, and oblivious of his
surroundings. Mentation is reduced to the very lowest ebb,
and ultimately all that remains is the instinct (or reflex) to take
food from a spoon when it is put to his lips, the patient’s condi-
tion being comparable with that of a newborn babe. Such
food may consist of soft solids for some weeks or even months;
but the time comes when liquid food only can be swallowed.
About three weeks later the deglutition reflex is completely
abolished and death from inanition follows in a couple of days.
Rather, however, than allow a patient to die from inanition, I
have him tube-fed to the last. Life may sometimes be prolonged
in this way for another six months.
Clinical Varieties.
Demented Form.—This form is characterized by progressive
mental deterioration without any great excitement, exaltation or
depression and without prominent hallucinations.
we —
VARIETIES OF GENERAL PARALYSIS 445
The patients lose their former energy and capacity for work,
become forgetful of details and commit errors of judgment.
They have some insight into their condition, and therefore seek
medical advice of their own accord. Not infrequently it happens
that a patient of this nature will enter an institution for the
insane as a voluntary boarder.
Deterioration of volition, instinct, emotion and memory take
place in the manner already described. The physical signs run
the usual course.
Expansive Form.—This includes the cases in which delusions
of exaltation predominate, in which the patient, in spite of his
tremulous articulation and tottering gait, declares that he never
felt better in his life (euphoria), is stronger than he ever was, is
able to lift tons and perform unprecedented athletic feats, is
the greatest poet, author, musician, artist, orator, financier and
crowned head that ever lived. So enormous are his supposed
possessions that he is generous to a fault; it is impossible to keep
him supplied with tobacco, for he distributes it freely to all the
other patients in the ward. Benevolence is one of the most
striking characteristics, not only of this form of the disease, but
of general paralysis as a whole.
There is another variety of the expansive form of the disease,
in which the patient enjoys a feeling of general well-being and
recounts with self-satisfaction all the beneficent and other pleasing
incidents of his past life, forgetting all unpleasant details; but he
never develops such bizarre delusions as those above enumerated.
Maniacal Form.—Here we have to deal with cases which, to a
casual observer, present the characteristics of a severe attack of
acute mania. The patient is wildly excited, noisy, dirty, destruc-
tive and dangerous. In addition he exhibits all the characteristic
signs of general paralysis—immobile pupils, exaggerated or
absent knee-jerks, tremors etc.
These cases are especially liable to remission. The patients
make an apparently complete recovery; the excitement passes
off, tremors disappear, and I have seen cases in which even the
light reflex and knee-jerk returned, both having been absent
during the attack of excitement. Subsequently the patient has
several similar attacks which leave him more and more demented.
It may be eight or ten years before he requires permanent asylum
care and his disease reaches its fatal termination. In some of
these cases expansive delusions may be associated with the
attacks of motor excitement.
It happens occasionally that the excitement attains the
446 MIND AND ITS DISORDERS
intensity and severity of acute delirious mania, with high tem-
perature, frequent pulse, sordes on the teeth and inability to
retain food, the patient passing rapidly into a typhoid state and
dying of exhaustion (galloping general paralysis).
Depressed Form.—This variety is almost as frequent as, if not
at the present day more frequent than, the expansive form. The
patient may have delusions of past wickedness and assert that —
his soul is lost or that he is ruined; but hypochondriacal delusions
are by far the commonest in this variety of the disease. His
throat or bowels are obstructed or on fire, his body is made of
glass and liable to fall to pieces if any attempt at movement be
made; he is so small that he weighs but a few ounces and can
get through the keyhole, so big that he cannot pass through
the doorway or he is dead and putrefying. As already stated,
many of these patients indulge in such grotesque exaggeration
of their affliction that there results that curious mixture of de-
pression and exaltation which is peculiar to general paralysis.
As with the maniacal form, remission is not uncommon in this
variety.
A few of the depressed cases develop delusions of persecution.
Such delusions are unsystematized and unlikely to lead to errors
in diagnosis.
Stuporose Form.—This is not a common variety. When it
occurs volition, instinct and emotion are in abeyance from the
first. The patient sits unoccupied in one position the whole dav
long, never engages in conversation and is “‘ wet and dirty’. He
is not depressed; the stupor gradually gives place to dementia,
the patient giving little or no evidence of mentation during the
whole course of the disease.
Circular Form.—This variety is also uncommon. There may
be an alternation of periods of excitement and depression with or —
without intervening periods of quietude.
Convulsive Form.—In some cases convulsions are the chief
clinical feature of the disease. It occasionally happens that a
person, suffering from hitherto unsuspected general paralysis,
suddenly has a batch of fits (status epilepticus) with hyper-
pyrexia and dies. This may be regarded as one form of galloping
general paralysis. In other cases the patient has frequent attacks
of status epilepticus or frequent isolated convulsions and the
disease runs a rapidly fatal course. Under such circumstances he
is said to be suffering from the convulsive form of the disease.
Female Form.—In women general paralysis is usually of the
demented or depressed variety without much tendency to the
VARIETIES OF GENERAL PARALYSIS 447
formation of delusions. Krafft-Ebing and Regis ascribe this
peculiarity to the relative poverty of ideation in women. Re-
missions are rare and the disease runs a more chronic course than
in males.
Juvenile Form.—Many cases have been recorded of general
paralysis occurring in congenital syphilitics during the second
decade of life. The physical signs differ in no way from those
of other cases; but the mental symptoms are somewhat different
on account of the patient’s mental evolution being, at the begin-
ning of the disease, yet incomplete. The mental symptoms of
the earliest cases accordingly resemble those of imbecility rather
than insanity. Remissions do not occur in this variety.
Tabetic, spastic and amyotrophic forms are recognized by the
French school. Apart from the spinal complications, these forms
only differ from ordinary general paralysis in that there is an
increased tendency for the disease to be of the depressed variety.
It is said that, should general paralysis develop in a patient who
has suffered for some years from the results of spinal lesions,
there is amelioration of the spinal symptoms.
Prognosis.—Left untreated, the natural prognosis of general
paralysis is grave. Most of the cases prove fatal within three
years; but it is not sufficiently recognized that a few completely
recover. The galloping forms of the disease run their course in
two or three weeks or even less. Three to six months is the
usual time for the convulsive form. Cases with alternative
excitement and depression seldom last much longer than twelve
months. Expansive cases usually reach their fatal termination
within two years. In the demented form the cases last rather
longer, about two and a half years as a rule, and the depressed
cases last from three to three and a half years. The outlook
is much more favourable in the excited cases, because these are
the most liable to remit. It is not at all uncommon for such
patients to live six to ten years before the fatal termination is
reached and, during a considerable portion of this time, they may
be well enough to do useful work. Many cases of apparent
recovery have been recorded in this variety of general paralysis.
On the other hand, excited cases which do not remit run a rapidly
fatal course.
Some depressed cases are also liable to remission, but this is
not so common as in cases of excitement.
In tabo-paralysis and in women the course of the disease tends
to be prolonged.
The proportion of cases in which remissions occur, as given
448 MIND AND ITS DISORDERS
by different writers, varies very considerably. Cotton analyzed
127 cases of general paralysis in which the diagnosis was con-
firmed by lumbar puncture and found that spontaneous remis-
sions were observed in only 4 per cent. Mapother and Beaton
give the proportion as 7 to 8 per cent., with an average duration
of eleven months. Dr. Noble, one of the House Physicians at
the Bethlem Hospital, kindly investigated for me the results of
a hundred consecutive cases occurring during the later nineties,
when no specific treatment was adopted, and he found that
remission occurred in 14 of them (14 per cent.).
As a rule the duration of these spontaneous remissions is from
six months to a year or so, but a few cases are found in literature
in which remissions lasted for four or five years, or even con-
siderably longer than this. An illustration of this is the case
of Tuczek, in which the patient was first attacked by general
paralysis at the age of thirty-six, the mental symptoms dis-
appearing two years later. This was followed by a remission
of twenty years, after which symptoms of general paralysis
again recurred, the patient dying at the age of fifty-eight. Nissl,
who made the post-mortem examination, found the changes in
the cortex characteristic of dementia paralytica. Another case
of this kind is reported by Dr. G. M. Robertson. The patient,
who lived thirty years after the onset of the disease, showed
typical symptoms for the first five years. Then followed a
remission of fifteen years, and after another attack, a second
remission of seven years, the symptoms reappearing during the
last two years of life.
It has frequently been observed that remissions are liable to
occur in patients who have been attacked by an acute illness,
especially an acute specific fever. It occasionally happens that
the patient develops a large phlegmon, perhaps in one thigh.
When this is opened or bursts spontaneously a large quantity
of muco-sanious fluid escapes and the progress of the disease is
arrested. Vallon and Doutrebente have published two such
cases, and I have heard of one other in Vienna.
The prognosis above given for general paralysis refers to un-
complicated cases which have not been treated by certain modern
methods, to be presently described, which give some hope of
our being able to do more for this disease thari has been achieved
in the past. The possibility of death from accidents, complica-
tions or intercurrent illness must always be borne in mind. In
any form or at any stage of the disease life may be suddenly cut
short by an attack of status epilepticus or the patient may acci-
DEATH OF GENERAL PARALYTICS ys:
dentally choke himself with a bolus of food; and, although
suicide is an uncommon mode of death in general paralysis,
it is liable to occur in depressed, especially hypochondriacal,
cases.
Broncho-pneumonia may be set up by food passing into the
bronchi; this is especially liable to happen to those patients who
refuse food and have it forced upon them with a feeding-cup
instead of an cesophageal tube.
Unless care and cleanliness are used in the treatment of those
who suffer from retention of urine and require the passage of a
catheter, the course of the disease may be shortened by cystitis,
suppurative nephritis and general septicemia. Similarly, unless
care be taken in the prevention and treatment of bedsores, an
acute fatal septicemia may develop.
A considerable number of general paralytics die of phthisis and
ulcerative colitis, which appear to be endemic in many of our
large public asylums, especially, as it seems, in those of fairly
recent construction. The tubercular opsonic index of general
paralytics is subnormal. Lastly, the disease may be complicated
by any ordinary intercurrent affection, such as pneumonia.
Treatment.— Until recently there were so many methods for
attempting to cure general paralysis that we could only conclude
that the problem had not yet been solved, although there were
people who claimed a certain amount of success for each one
of them. It may be said at once that ordinary antisyphilitic
treatment with mercury, iodide of potassium, salvarsan or one
of its substitutes is of no avail because these drugs do not reach
the seat of the disease. They cannot pass the barrier of the
choroid plexuses, which acts as a kind of filter, and they therefore
fail to enter the cerebro-spinal fluid.
A specific attempt to kill the spirochetes in the cerebral tissue
has been made in a large number of ways. Probably the earliest
drug to be used for this purpose was hexamine.
Hexamine (10 to 20 grains), given three times a day in com-
bination with twice the quantity of acid sodium phosphate,
appears in the cerebro-spinal fluid as a weak solution of formalin
(about x in 20,000). Apparently it does not kill the spirochetes
as a rule, but it has the advantage of killing other micro-organisms
usually present in the cerebro-spinal fluid of general paralytics
(the diplococcus of Porter Phillips and the diphtheroid of Ford
Robertson, for example), and thus of preventing convulsions of all
kinds. Moreover, in my experience about 25 per cent. of general
paralytics treated with hexamine haye remissions and 17-6 per
29
450 MIND AND ITS DISORDERS
cent. do not relapse or I have not heard of them again. I cannot
but conclude that some of these cases are recoveries.
Alcohol is another drug that finds its way past the barrier of
the choroid plexuses and enters the cerebro-spinal fluid, and I
have noted in three or four cases of general paralysis marked
improvement after an alcoholic bout. For these reasons I allow
alcohol (preferably brandy-and-soda) to general paralytics after
they have started a course of hexamine, in spite of the fanatical
teetotal propaganda of the present day, and have been gratified
with the rapid improvement in many cases and the number of
remissions. Some of these may prove to be recoveries, but the
least that can be said for such treatment is that no general
paralytic patient of mine ever has convulsions.
More recently tryparsamide, a drug which has been used since
1919 for the treatment of trypanosomiasis (sleeping sickness)—a
disease in many ways analogous to syphilis—has been used for
general paralysis in America and at the Maudsley Hospital with
very promising results. The success of this drug is due to the
fact that it passes the choroid plexuses, and according to the
published results it induces a remission in about two-thirds of
the cases; but it is, of course, too soon to say whether these are
cures. It is unfortunate that up to the present tryparsamide
can only be obtained from the Rockfeller Institute, whose supply
is naturally somewhat limited.
In the last edition details and criticisms were given of the
many methods which have been employed in attempts to treat
the disease more specifically by introducing salvarsanized serum
or mercurialized serum or both into the cerebro-spinal fluid, either
by lumbar puncture or into the cranial cavity by operation; but
all these have since been practically abandoned in favour of
the malarial treatment presently to be described.
Another method of treating general paralysis is based on an
entirely different principle. It owes its origin to the observation
that remissions are especially liable to occur after an attack of
some acute specific fever and, in years gone by, physicians used
to attempt to produce suppuration artificially. Ointment of
tartarated antimony used to be rubbed into the scalp, the treat-
ment being sometimes continued until small pieces of bone were
detached from the skull; but it is scarcely necessary to say that
such an extremely energetic procedure was not by any means
devoid of danger to the patient.
It is obvious that it would involve too great a risk deliberately
to infect a general paralytic with, for example, enteric fever for
TREATMENT OF GENERAL PARALYSIS 451
the purpose of inducing a remission, or even a possible cure; but
Pilcz of Vienna hit upon the idea of injecting doses of tuberculin
with the object of exciting a febrile attack. How such febrile
attacks effected the desired result is not definitely determined,
but the opinion of most physicians was that the accompanying
pleocytosis served to combat any organism which might be
responsible for general paralysis. According to the experience
of syphilologists the entrance of the causative agents of septic
disease tends to inhibit the growth of the spirocheete, and it
therefore appears possible that the toxic products of such bacteria
might form a combination against those responsible for general
paralysis. As the tuberculin treatment has not survived we
need say no more about it in this edition.
The malarial treatment owes its inception to Wagner-Jauregg
of Vienna, where it has been tried since 1917 on the largest scale.
In 1925 Gerstmann published the results of the cases treated
there between 1917 and the end of 1922, and they are given in
the following table, which was published in a paper by Professor
Yorke in the Lancet of February 27, 1926:
RESULTS OF MALARIAL TREATMENT IN 400 GENERAL PARALYTICS AT
VIENNA, COMPILED FROM INFORMATION SUPPLIED BY GERSTMANN
(1925).
| | Slight Change,
Date Treated. Wee Local Compile | ita: no Change,
) Cases, | Remission. | Remission, | or Dead.
IQI7 re ae ie 9 4 | 2 3
I9QIQ—-1920 .. me ae 25 8 3 | 14
1920-1921 .. - Be 116 38 14 | 64
I92I-1922 .. ie ay 250 83 40 | 127
FF OtAL. s ~ . 400 133 (33°95) 59 (15%)| 208 (52%)
|
From this it may be gathered that the malarial treatment cures
one-third of the patients. The earlier the patient is treated the
more successful is the result likely to be, while one cannot
hope for anything like a cure in patients who have suffered from
the disease for more than one year.
The treatment consists of infecting the patient with simple
tertian malaria (Plasmodium vivax). This is usually done by
injecting infected blood into a vein of the patient, but another
method is to allow infective anopheline mosquitoes to bite the
452 MIND AND ITS DISORDERS
patient. Arm-to-arm inoculation is easily carried out in mental
hospitals, but there is a little difficulty in treating isolated cases
because the malarial parasite lives only a very short time 17 v1tro.
Poetzl of Prague, however, gives the following technique for
preserving the blood: ‘‘ On withdrawal the blood containing the
parasite is defibrinated by shaking it up with glass beads in a
flask or test-tube under sterile conditions; the fluid, containing
corpuscles and parasites, is transferred to another sterile tube,
and this is kept in the ice chest or, for immediate despatch,
packed surrounded by ice in a thermos flask.’’ Dr. R. M. Clark
of the Lancashire Mental Hospital, Whittingham, Preston,
states that the blood so prepared is effective for at least sixty-
five hours, and he does not regard even this time as the outside
limit; 2 c.c. of such blood are sufficient to give the patient
malaria. After an incubation period of usually one to three
weeks, he has his first malarial attack, lasting about ten
hours. Typically the subsequent attacks should occur every
other day, but one often finds irregularities in the periodicity.
It is customary to allow the patient to have twelve such
attacks.
No medicine should be given. Adherence to this rule some-
times requires a great deal of moral courage, for sometimes the
paroxysms may be very severe and the patient alarmingly ull.
One does not wish to have it on one’s conscience that the patient
has died of malaria; on the other hand, to stop the treatment
too soon would spoil the whole procedure and result in failure to
cure the general paralysis. Moreover, it must not be forgotten
that the patient cannot be infected again until after the lapse
of many months. Hyperpyrexia during the paroxysm should
be controlled by cold sponging. After the twelfth malarial
paroxysm, or before this if the patient’s life is in danger, quinine
is administered in solution, 5 grains every four hours for three
or four consecutive days. This cures the malaria, which is rather
surprising when we consider the comparative difficulty of curing
ordinary tropical malaria. It is said that the prognosis is much
better when the clinical manifestations clear up before the changes
in the cerebro-spinal fluid than when this sequence of events
is reversed.
Donath, and subsequently Fischer, Lépine and others, on the
assumption that the leucocytosis associated with infective con-
ditions might possibly have a favourable influence on general
paralysis, adopted the expedient of using a drug which is
known to have the effect of inducing a well-marked hyper-
TREATMENT OF GENERAL PARALYSIS ADS
leucocytosis, viz., nucleinate of soda. They use the following
solution :—
Sodium nucleinate .. Sa a ie 2) patta:
Sodium chloride nae a Pr ms 2 parts.
Sterilized distilled water ig he .. 100 parts.
Donath recommends seven injections of this solution sub-
cutaneously at intervals of five days. In the first place 50 c.c.
are injected, and on subsequent occasions 100 c.c. A febrile
reaction follows, and if this fails to occur larger doses should
be given. Donath states that he has given as much as 180 c.c.
in a single dose. With this treatment he obtained a remission
in 13 of 36 cases (about 35 per cent.). Fischer obtained re-
missions of considerable duration in 4 of 22 cases, and is of
opinion that the juvenile type of general paralysis is especially
suitable for this mode of treatment. Purves Stewart also
obtained more or less prolonged remissions in several cases.
At one time I seemed to have some success from the use of
nucleinate of soda, but more recently I have lost confidence
in it.
The great disadvantage is the enormous quantity of fluid
which it is necessary to inject, and nucleic acid in a more con-
centrated solution has been suggested as a substitute. I have
tried it, but cannot say that it proved successful. In fact my
experience was somewhat curious; the leucocyte count went
down and stopped down.
Pilcz has made the observation that, although a good pleo-
cytosis is usually induced by initial doses of a leucocytosis-
producing substance, the organism soon becomes accustomed
to them and no leucocyte reaction takes place, even though a
rise of temperature occurs. He accordingly modified his original
method by varying the substance used. On one day he injects
0°02 grm. of succinamide of mercury, on another 0°005 grm.
of tuberculin, perhaps increasing the dose to a gramme. This
is varied with injections of dead cultures of staphylococci,
streptococci, nucleinate of soda, salvarsan, and so on. I know
of no published results of this method, but it seems to be the
general opinion that it is more successful than the use of tuber-
culin alone.
Apart from any attempted specific treatment, the general
paralytic should be placed in healthy surroundings and induced
to live in the open air as much as possible, just like a tubercular
patient. He must be well fed on a liberal, nutritious, minced
diet with plenty of milk.
454 MIND AND ITS DISORDERS
Insomnia is not usually a troublesome symptom in this disease,
but, should it occur, and be serious enough to demand drug
treatment, isopral should be given. This drug appears to have
a specific action on the disease, perhaps because it is an alcohol.
Motor excitement may be allayed by prolonged baths as in
the case of an ordinary attack of acute mania. Any tendency to
convulsions may be combated with bromide of potassium, chloral
hydrate or, in status epilepticus, with a hypodermic injection of
morphia. A drop of croton oil is sometimes useful in cutting
short an apoplectiform attack in patients who are not being
treated with hexamine.
Retention of urine should, of course, be treated by the regular
use of a clean aseptic catheter. Bedsores are to be prevented
by keeping the patient clean and dry. Should they occur in
spite of precaution, they must be first rendered aseptic by the
use of turpentine fomentations and subsequently painted with
several layers of the compound tincture of benzoin.
Morbid Anatomy.—The most striking feature of the morbid
anatomy of general paralysis is the diffuseness of the lesions.
Almost every organ of the body, on careful examination, shows
some degenerative change, so that no doubt exists in the mind
of the pathologist that the disease is of toxic origin.
The calvarium, on removal, is found to be thickened, the diploé
being obliterated (hyperostosis), especially in its anterior part;
as a result, it is two or more ounces heavier than is natural.
Much less frequently the bones of the skull are thin and the diploé
well marked (rarefying osteitis). Hyperostosis is not often
observed elsewhere. Rarefying osteitis is occasionally observed
in the long bones. In such cases an abnormal brittleness of the
bones may have been a clinical feature during life and at the post-
mortem the ribs may be broken like a biscuit between the fingers.
There is almost invariably hypostasis and cedema of the lungs
and there may be foci of bronchopneumonia. Well-marked
atheroma aorte occurs in about 35 per cent. of the cases and
slight atheroma or endarteritis in about 45 per cent. In the
heart atheroma of the mitral valve is fairly common; the muscle
is pale and flabby and, if a portion be teased out in osmic acid,
fatty degeneration can usually be determined under the micro-
scope. Some fatty degeneration can frequently be observed in
like manner in the liver and there is occasionally some cirrhosis.
Slight parenchymatous nephritis, or at least granular degenera-
tion of the renal cells, is also common. D’Abundo states that
vesical and prostatic lesions are of frequent occurrence.
BONE CHANGES IN GENERAL PARALYSIS 455
But the most striking lesions of all are those of the nervous
system and meninges. The dura mater is thickened and adherent
to the calvarium, especially along the sagittal suture. In some
cases it is lined with a false membrane varying in thickness up
to 1 inch and consisting of an organized clot of blood which
has escaped from degenerate vessels of the dura mater. The
membrane grows in thickness owing to degeneration and rupture
of newly formed vessels in the membrane, thus forming a fresh
layer of blood which in turn becomes organized into another layer
of membrane. This process, which is known as “‘ pachymenin-
gitis hamorrhagica interna’’, may be repeated several times.
Calcareous plates are sometimes found in the substance of both
the cranial and spinal portions of the dura. The arachnoid is
thickened and opalescent. Where it bridges over sulci it shows
milky spots and streaks along the course of small vessels. The
Pacchionian bodies are increased in number and hypertrophied.
The pia mater is thickened and cedematous, its meshes being
distended with pale yellowish fluid. There is also a great excess
of cerebro-spinal fluid about the base of the brain and in its
dilated ventricles, partly due to an increased production, as
indicated by the high pressure observed when a lumbar puncture
is performed, and partly contingent upon the loss of cerebral
substance by wasting.
The brain commonly weighs about 44 ounces or less instead
of the normal weight, 48 ounces (male). On stripping the pia
mater from the convolutions and dissecting the brain much fluid
escapes, so that it commonly happens that the dissected brain
weighs 3 ounces less than on removal from the body. The left
cerebral hemisphere weighs less than the right, thus giving evi-
dence that it, being the more voluntary, more highly evolved and
therefore more unstable hemisphere, suffers from the morbid
process more than the right hemisphere, its inferior brother,
On attempting to strip the pia mater from the cerebrum small
portions of brain substance from the summits of the convolutions
remain adherent to the membrane, leaving small lacerated areas
on the cortex (decortication). This feature is absolutely charac-
teristic of a general paralytic brain, provided that the interval
between death and the autopsy is not much prolonged. It 1s
said by some to be due to rapid post-mortem softening of the
grey matter.
The convolutions are wasted and the sulci widened in con-
sequence and the grey matter is seen on section to be thinner
than natural; these characters are most marked in the anterior
456 - MIND AND ITS DISORDERS
half of the cerebral convexity. The white matter on section is
shiny owing to excess of fluid; puncta cruenta are well marked
on account of dilatation of vessels and the perivascular spaces
are sometimes visible to the naked eye in the more superficial
parts of the white matter. Some cases, which during life have
been subject to apoplectiform attacks, are found at the autopsy
to have small foci of softening in the optic thalamus.
The ventricles are dilated and their ependyma frequently ©
presents a granular, frosted aspect which has been compared
to the appearance of the ice-plant. This is best seen, when
present, in the floor of the fourth ventricle.
Histological Changes.—Since the sequence which an author
adopts in describing the microscopical appearances depends upon
his own interpretation of the changes, a preliminary considera-
tion of various views as to the nature of the disease may not be
out of place.
For many years pathologists have ranged themselves on
opposite sides, according to the view they hold of general para-
lysis being either a primary inflammatory or a degenerative
change in the cerebral cortex. Such a discussion need not detain
an unbiassed observer, for it resolves itself at bottom into a
mere quibble about words. If by inflammation we mean “ the
reaction of a tissue to injury which is insufficient to destroy its
vitality ’’, then, as we shall see, inflammatory processes are
certainly at work in the cortical meninges, neuroglia and blood-
vessels. On the other hand, we shall see also reason for supposing
that the cortical neurons may undergo primary degeneration,
although at the same time subjected to processes causing secon-
dary degeneration. Our contention is, then, that both schools
of pathologists are right.
The question whether the neural degeneration is primary or
secondary to changes in the glia, bloodvessels and perivascular
canals may be similarly answered. It is unlikely that such
unstable elements of the cortex as the neurons would escape
primary degeneration while neighbouring mesoblastic elements
are suffering from the morbid influence of a toxic environment.
On the other hand, it will be seen that the morbid changes in the
mesoblastic elements are more than sufficient to interfere with
the nutrition and to cause secondary degeneration of the neural
elements.
The earliest change takes place in connection with the vascular
(blood and lymph) systems of the cortex. The vessels of the
pia become distended with blood and there is nuclear prolifera-
PLASMA CELLS 457
tion in the walls of the arterioles and perivascular canals with a
copious formation of new capillaries. There is overgrowth of
the endothelial cells of the capillaries and, on their adventitial
sheath, which normally consists of elongated cells, there develops
a regular felt-work of similar cells having special characters
(plasma-cells). In this situation they are peculiar to general
paralysis. They lie at right angles to the cortex; they have
Fic. 69.—A SMALL CorRTICAL VESSEL IN THE OCCIPITAL LOBE OF A
GENERAL PARALYTIC, SHOWING TYPICAL PLASMA CELLS (x) UPON IT.
Note the oblong, angular or oval shape with a clear space in the cyto-
plasm and the laterally situated nucleus with its darkly stained chromatic
bodies. (X800.) [Negative kindly lent by Dr. John Turner.]
traces of protoplasm at both ends and a clear centre containing
very minute granules which stain with methylene blue and the
nucleus is seen in transverse sections to occupy an eccentric
position. By some these “‘ plasma-cells ’”’ are regarded as altered
leucocytes, by others as derivatives of glia-cells. The latter view
seems untenable, because similar cells may be found in the peri-
458 MIND AND ITS DISORDERS
vascular tissues in almost any focus of chronic inflammation in
any part of the body. Nor is the view that the plasma-cells are
altered leucocytes easy of acceptance, for they bear no resem-
blance to leucocytes. Their resemblance to normal cells of the
adventitial sheath is, on the other hand, somewhat striking,
and suggests a more probable source of origin. A peculiar rod-
shaped cell is also seen in the cortex, Nissl’s Stdbchen cell, which
Alzheimer believes to be derived from cells of the bloodvessels —
and Mott regards as collapsed capillaries in section.
seperate
A 5 Fe
a a? eb ee eee
nce Ea inci i hd eee MNES Sn es a
Fic. 70.—A GLIA OR SPIDER CELL FROM THE CORTEX OF A GENERAL
PARALYTIC’S BRAIN.
The stout, vascular fibres ending in fan-like expansions by which they
are attached to the walls of the bloodvessels are well shown. A film
preparation. (X600.) [Negative kindly lent by Dr. John Turner.]
Meanwhile there is diapedesis of leucocytes into the peri-
vascular spaces, which become further choked by mast-cells and
hyaline débris, probably derived from degenerate nerve-cells.
Mast-cells are also present, connective tissue leucocytes with
basophile granules. This choking of the perivascular canals,
associated with thickening of the capillary walls, causes great
interference with nutrition of the neural elements of the cortex.
The neuroglia undergoes proliferation. The spider-cells are
especially numerous, not only in their normal situations, but also
SPIDER CELLS 459
in the deeper layers of the cortex where normally they are not
to be found. Some of the new-formed spider-cells become three
or four times the normal size (monster-cells).
Many of the cortical nerve-cells become strangled by the over-
growth of neuroglial fibres. Overgrowth of the neuroglia is also
responsible for the granular appearance of the ventricles already
described. Karyokinetic figures. are occasionally observed in
the nuclei of the glia-cells.
It has been demonstrated by Dr. Bevan-Lewis that some of
these spider-cells in the neighbourhood of a perivascular canal
be 7 a 3
We
Fic. 71.—SPIDER CELLS IN THE INNERMOST CORTICAL LAYER FROM THE
BRAIN OF A CASE OF CHRONIC INSANITY, SUBJECT TO EPILEPTIFORM
SEIZURES AND WITH A PROBABLE HISTORY OF ALCOHOLIC INTEMPER-
ANCE.
a=Spider cell, with many branches, one of which is attached to a vessel;
b=vascular attachment with fan-shaped expansion on vessel (the cell to
which this branch belongs is out of the field of section}. (Xx600.) [Nega-
tive kindly lent by Dr. John Turner. ]
have one process longer than the others, with its end expanded
and closely applied to the perivascular lymphatic. It has been
inferred that such cells assume a migratory function and serve the
purpose of scavengers by absorbing the effete products of neural
degeneration and excreting them into the perivascular spaces.
As a result of these three morbid processes (intoxication, dis-
turbance of nutrition by interference with the circulation of
460 © MIND AND ITS DISORDERS
blood and lymph in the cortex, strangulation by the overgrowth
of neuroglia) there is extensive destruction of the cortical neurons.
The earliest destruction of nerve-cells usually takes place in the
physical basis of the most highly specialized functions, especially
in the motor centre for speech, but it is best studied in the large
cells of Betz in the mid-Rolandic area.
Chromatolysis is the first change: the chromatic granules
become powdery and ultimately disappear. The fibrous achro- —
matic substance then suffers (achromatolysis) and the nucleus
loses its central position, becomes displaced by the periphery and
finally extruded. The nucleus, which normally remains un-
stained in preparations by Nissl’s method, takes the stain in
degenerate nerve-cells; while the nucleolus does not take the
stain as well as in a normal specimen.
In sections prepared by Cox’s method (see Appendix A) it
may be seen that there is a deficiency of gemmules on the proto-
plasmic processes (dendrons) and that they are replaced by
localized thickenings or varicosities.
Lastly, on the death of the cell-body there is degeneration of
its axon. Degeneration of the pyramidal fibres may be demon-
strated in the white matter and in the spinal cord by Orr’s modi-
fication of Marchi’s method. According to Orr and Cowen,
the degeneration is most marked in patients who have during
life suffered from convulsions.
The tangential layer of fibres is atrophied.
Bianchi mentions atrophy of the nerve-fibres of the cere-
bellum and Roecke has described an increase of the fibres of
Bergmann in the molecular layer of that organ.
More important than all these observations is that of Noguchi,
confirmed by many pathologists, that spirochetes can be demon-
strated by various methods to be present in large numbers in
the substance of the cortex cerebri, mostly at the frontal and
temporo-sphenoidal poles. The best place to find them is on
the mesial surfaces of the frontal lobes, especially where these
are adherent to one another. The organisms are distributed
in groups of hundreds, between which groups not a single spiro-
chete is to be found, so that one need not be discouraged by
failure to demonstrate them in the first preparation.
All the cranial nerves show degenerative changes by the Marchi
method, many of the medullary sheaths being studded with little
black patches. Vassale has pointed out that degeneration of
this nature is characteristic of a primary lesion of the fibres
from the direct action of a toxin and is not of the nature of a
CEREBRO-SPINAL FLUID AGT
Wallerian degeneration dependent upon lesions of the cranial
nuclei.
Degeneration of the column of Burdach is common, as seen
in Weigert-Pal preparations, not only in tabetic cases but also in
many others which have not shown tabetic symptoms during
life. The central canal of the cord is filled with nuclei in some
places and distended in others. The anterior and posterior spinal
roots usually show signs of primary degeneration.
If a comprehensive view be taken of the lesions above described,
it will be seen that the parts of the nervous system which suffer
most are those which are most accessible to the cerebro-spinal
fluid :—the dura mater and pia arachnoid; the cortex, especially
the motor cortex, with its abundant supply of perivascular
lymphatics; the tangential fibres; the cranial nerves and spinal
nerve-roots; the walls of the ventricles, especially the floor of
the fourth ventricle over which every drop of cerebro-spinal
fluid must flow on its way from the choroid plexuses to the
foramen of Magendie; the central canal of the cord; the pulvinar
and the cortex of the cerebellum. The tract degenerations in
the interior of the central nervous system are all secondary to
these lesions. The conclusion appears to be irresistible that the
specific toxin of general paralysis is to be found in the cerebro-
spinal fluid and that it is already present when that fluid is
secreted from the choroid plexuses.
Now although this fluid has been the object of most careful
chemical and histological examination, the toxin appears to
have hitherto eluded observation; but we now know from
Noguchi’s discovery that it is a spirochetogenic toxin. There
- is excess of albumin and nucleo-proteid in the fluid; and cholin,
one of the products of degeneration of nervous tissue, is to
be found in the fluid. Cholin is a substance known to be
capable of both lowering the blood-pressure and inducing fatty
degeneration of tissues. It may therefore be held responsible
for the extensive fatty degeneration found in patients who
have died of general paralysis and also for the lowered blood-
pressure, reported by Sir Maurice Craig, in the terminal
stages of the disease. Dr. J. Turner found sugar to be deficient
in lumbar puncture fluid of general paralysis and ascertained that
it entirely disappeared post mortem. It occasionally happens
that the fluid coagulates shortly after it has been collected,
quite apart from any admixture of blood from subdural
hemorrhage or otherwise.
The pressure of the cerebro-spinal fluid is abnormally high.
462, MIND AND ITS DISORDERS
Schaeffer made fifty-three punctures in twenty-five cases and
found an average pressure of 182 millimetres; in two-thirds of
his cases the pressure was between 250 and 280 millimetres,
whereas the normal pressure is certainly less than 150 milli-
metres.
For cell changes in the cerebro-spinal fluid see Fig. 72 and.
Appendix B. The colloidal gold test for general paralysis is
also described in Appendix B. |
Psychopathology.—Hollos and Ferenczi have made a psycho-
analytical study of the psychic disorder of general paralysis, not
by subjecting general paralytics to psycho-analytical technique,
but by giving their own interpretations of certain symptoms of
the patients as in applied psycho-analysis.
It is especially from a study of the delusions respecting age,
time, duration, numbers and such like that Hollos concludes that
these wish-fulfilments relate to the inception of the disease (either
the syphilis or the first mental difficulties), as if the patient is
seeking to escape from the truths of reality (the facts of his
disease) from that date onward. In other words general paralysis
is a patho-psychosis analogous to Ferenczi’s patho-neurosis. The
delusions of strength and well-being are a reaction against the
patient’s weakness and malaise, while the depression in the
depressed cases is again found by interpretation to refer to the
malady itself.
In addition to all this the physical degeneration of the cerebral
cortex weakens the repressing forces of the patient, and he
therefore regresses to an infantile instinctual life, the colouring
of the clinical picture varying, and the man is, for example,
strongly narcissistic, oral-neurotic or sadistically anal-erotic.
ay
ial
ENDOTHELIAL CELL
ts,
Sa \n\
fy c' SPINDLE CELL
PLASMA CELL—/— ee Ve (Fisro BLast @)
PHAGOCYTE
GincLusion oF
LYMPHOCYTE
ENDOTHELIAL
CELL
MITOTIC CELL
? PLASMA CELL
LYMPHOCYTE —& ¥ PLASMA CELL
ENDOTHELIAL CELL
Pitre
FILM MADE FROM THE CEREBRO-SPINAL FLUID OF A GENERAL PARALYTIC
STAINED WITH PAPPENHEIM'S PYRONIN-METHYL-GAEEN
Preparation and Drawing by Dr J. G. PHILLIPs
To face page 462
CHAPTER XVIII.
MENTAL DISORDERS ASSOCIATED WITH COARSE
CEREBRAL LESIONS.
In this chapter we have to consider the characters and relation-
ships of mental disorders arising in association with and appar-
ently resulting from—
1. Injury to the head.
2. Embolism or thrombosis of one or more cerebral arteries,
whereby some part of the brain is destroyed and dies for want of
blood-supply.
3. Cerebral hemorrhage, abscess or tumour destroying some
local portion of the brain-tissue and causing an increase of the
general intracranial pressure.
4. General inflammatory conditions such as encephalitis and
meningitis.
In many cases of organic cerebral disease the mental disorder
conforms to one of the types already described in this manual.
In such circumstances the brain lesion is to be regarded merely
as a contributory cause of the mental syndrome since the latter
presents no characteristic symptoms of a coarse brain lesion.
It is to be remarked that the presence of organic brain disease
renders recovery improbable, even in cases of an apparently
functional psychosis the prognosis of which is usually regarded
as favourable. Such cases require no further notice in the present
chapter, which is devoted to the consideration of the symptoms
directly traceable to the brain lesions.
These symptoms may be classified under three headings, ac-
cording to their causation by—
1. Increase of intracranial pressure.
2. Cerebral intoxication by products of neural disintegration or
3. Interference with some portion of the cortex which has a
specialized function in mentation.
Symptoms of Increased Intracranial Pressure.—These occur in
cases of abscess or tumour of the brain, in meningitis and in
encephalitis.
463
464 MIND AND ITS DISORDERS
Headache is the most common symptom. As a rule this is —
fairly persistent, but sometimes it is paroxysmal. It is usually
worse in the early morning, when it is commonly associated with
vomiting ; but the headache associated with gummata of the brain
is frequently worse at night.
Double optic neuritis occurs in about 80 per cent. of Athy cases
of cerebral tumour and of tubercular meningitis; it is much less
frequent in cases of simple cerebro-spinal meningitis. |
Vomiting is another fairly constant phenomenon. It appears
especially in association with exacerbations of the headache and
not uncommonly it is replaced by a feeling of nausea.
Generalized convulsions occur in a small number of cases.
The pulse and respiration are less frequent than normal, the
latter being affected more than the former.
The mental symptoms comprise a general retardation of the
mental faculties, with slowness of movement, slowness of speech
(bradyphasia), slowness of perception, apathy and loss of memory.
Puerility is also a somewhat characteristic symptom; the patients
are childish in their tastes and like to follow childish pursuits,
but they lack the activity and lively curiosity of the child. In
the later stages drowsiness sets in and gradually deepens to
stupor and coma.
Some of the above symptoms have been described, at least in
part and notably by the French school, to intoxication by the
products of neural disintegration, but the view is little accepted
in this country.
Symptoms of Cerebral Poisoning by Products of Neural Dis-
integration.—These are the symptoms already described under
the heading of Acute Confusional Insanity, to which disease
the reader is referred. Here they need only be summarized as
follows: peripheral analgesia, imperception, disorientation in
time and place, hallucinations (especially of vision and hearing),
disturbance in the association of ideas leading to incoherence of
speech, loss of memory, lack of volition with inability to con-
centrate the attention, apraxia and degeneration of the instincts
with mischievous and often dirty habits.
Focal Symptoms.—The psychical symptoms associated with
tumours of the frontal lobe are more liable to occur with sub-
cortical than with cortical tumours. The symptoms are of two
kinds, active and passive.
Among the active symptoms are irascibility, irritability, petu-
lance and quarrelsomeness. There is loss of control of the
instincts and the patients sometimes fall into the hands of the
ORGANIC BRAIN DISEASE 465
police through degeneration of the moral sentiment. This occurs
most commonly in association with tumours near the orbital
surface of the frontal lobe. Joviality, inability to take the
medical examination seriously, frivolity and a persistent tendency
to jest are said by some authorities to be characteristic of frontal
tumours. The symptom has received the names “ Witselsucht ”’
and “‘ Moria’’. Perhaps it arises most commonly in association
with frontal tumours, but it may occur with tumours of other
regions, and also in some cases of dementia of apparently func-
tional origin.
The passive symptoms of frontal tumour are obtuseness,
hebetude and loss of memory.
It is said that the passive symptoms occur more frequently
with tumours of the left and active symptoms with tumours of
the right frontal lobe. It may now be considered as settled that
the physical basis of voluntary action is situated in the left
frontal lobe and that apraxia or paralysis of volition indicates
disorder (functional or organic) of the same region. Left-sided
apraxia occurs in association with lesions of the right frontal lobe,
and bilateral apraxia is also caused by lesions of the anterior part
of the corpus callosum.
From a neurological point of view tumours of the corpus
callosum resemble those of the frontal lobes in that they give
rise to none of the symptoms looked for by the pure neurologist.
There is no disturbance of sensation or movement, or any charac-
teristic alteration of the reflexes; tumours of this region cannot
be diagnosed neurologically until they are large enough to
involve neighbouring structures; the earliest symptoms are
mental. It is not surprising that tumours of the corpus callosum
are invariably associated with psychical symptoms when we
consider that such tumours interfere, not only with the associa-
tion fibres constituting the great commissure connecting the
two cerebral hemispheres, but also with those of the superior
longitudinal bundles. The patients are dull, obtuse and con:
fused. They are disorientated in time and place and there is
complete loss of memory for recent events. There is inter-
ference with the association of ideas, leading to incoherence of
speech. Voluntary action, including voluntary attention, is in
abeyance. Judgment is deficient, and the patients are quite
incapable of mental work of any kind or of sustained physical
work. In other words the clinical picture is that of profound
dementia.
Tumours of the posterior half of the cortex of the left temporal
3°
466 MIND AND ITS DISORDERS
lobe induce (in right-handed people) word-deafness; they cannot
understand what is said to them (verbal auditory imperception).
A lesion of both temporo-sphenoidal lobes produces complete
auditory imperception so that the patient cannot, for example,
recognize music or the ringing of bells as such; but this may
also arise from extensive left-sided lesions. Subcortical and
supracortical tumours in the neighbourhood of the auditory
centre are liable to induce hallucinations of hearing. .
Tumours behind the left angular gyrus give rise (in right-handed
people) to loss of perception and ideation of written language
(word-blindness). The patients are unable to comprehend the
meaning of written or printed words or sentences. Usually they
are unable to express their thoughts in writing. They can copy
writing into writing and print into print, just as an average
Englishman could copy Chinese without knowing the meaning;
but they cannot copy print into writing or writing into print,
because such a process involves an act of perception of the
nature of the symbols which are being copied. This imper-
ception is for written and printed language only; objects can
usually be recognized and named at sight. It is probable that
lesions of both angular gyri (right as well as left) produce com-
plete visual imperception. Occasionally complete visual imper-
ception is caused by very extensive lesions of the posterior half
of the left hemisphere, involving the occipital and portions
of the parietal and temporal lobes with the subjacent white
matter.
When a lesion of the left angular gyrus is sufficiently extensive
to involve also the posterior part of the temporal lobe, the
patient is unable to name objects at sight although he recognizes
them and knows the uses to which they may be put. Delirium,
stupor and states of mental confusion with hallucinations are
especially liable to occur in association with tumours of this
region. Lastly, subcortical and supracortical tumours in the
neighbourhood of the angular gyrus tend to produce visual
hallucinations.
Lesions of the base of the brain are not especially apt to cause
mental symptoms unless they are in the neighbourhood of the
pituitary body. In the latter region tumours tend to produce
loss of the sexual instinct, with depression and suicidal ideas.
In a few cases there is maniacal excitement or delirium with
hallucinations.
Some idea of the frequency with which tumours in various
regions of the brain are associated with mental symptoms may
FOCAL SYMPTOMS 467
be derived from the following table compiled by Schuster from
the study of 588 cases, of which 323 showed mental symptoms:
Per Cent.
Tumours of the corpus callosum .. a eee LOO
Tumours of the frontal lobe be Fae oe 79°3
Tumours of the temporal lobe .. he RS 66:6
Tumours of the pituitary region .. ot 2 65°3
Tumours of the occipitallobe .. oe ae 60
Multiple tumours ae is oe a 59°6
Tumours of the pineal gland 4 ite se 53°8
Tumours of the parietal lobe me a os 52°1
Tumours of the basal ganglia... oe an 50
Tumours of the cerebellum ae ne . 35°5
Tumours of the centrum ovale... ee a 28°8
Tumours of the cerebral peduncles S ae 25
The mental enfeeblement which is met with in cases of cerebral
softening from thrombosis of one or more of the cerebral arteries
is an exaggerated form of that described under the heading of
Chronic Cortical Atrophy (Arteriopathic Dementia).
In acute cerebro-spinal meningitis and in acute encephalitis a
certain amount of mental and motor excitement is liable to occur
during the prodromal stages; but, as the disease becomes estab-
lished, the patient is more liable to become depressed, this
depression being the forerunner of the terminal coma.
The mental symptoms accompanying tubercular meningitis
are less uniform in character. Some patients are excited and
violent, others are depressed, others again develop delusions
of persecution. Many are delirious and experience numerous
hallucinations, while yet others show progressive mental deteriora-
tion resembling dementia.
There is no form of mental disorder which may be regarded
as characteristic of head injury, even with traumatism to the
brain. The cases conform to types of insanity elsewhere
described in this volume and the head injury must be regarded
merely as an exciting cause in a predisposed individual.
For the prognosis and treatment of the various organic diseases
of the brain mentioned in this chapter the student must consult
a work on neurology or general medicine.
CLA Pi geo
ENCEPHALITIS LETHARGICA, EPIDEMIC ENCEPHALITIS,
LEE PY SLC ION Bae
ALTHOUGH many of us can look back upon some case which, in
the light of our present knowledge, we now regard as one of
encephalitis lethargica, and although several physicians have
brought forward a certain amount of evidence to show that, even
in its epidemic form, this is no new disease, it has been at least
so rare that it has not received sufficient recognition to acquire
a name until it made its practical début in worldwide epidemic
form towards the end of the Great European War. Apparently
the first cases (described by von Economo) occurred in Vienna
in 1916, while in this country the epidemic reached a climax in
1921, when 1,470 cases were notified. Since that time the
numbers have been for 1922, 454 cases; for 1923, I,123 cases;
but the incidence of the disease continues to increase very
seriously, for in the first quarter alone of 1924 there were 2,468
cases notified.
Etiology Dr. A. S. MacNalty of the Ministry of Health
regards this as an entirely new disease. However that may be,
it would seem that the conditions of war supplied some pre-
disposing factor. The same may be said of poliomyelitis, polio-
encephalitis and influenza which, on the one hand, are supposed
by many authorities to be bacteriologically related to encephalitis
and, on the other, occurred in an increased epidemic form almost
contemporaneously with, but really slightly before, the en-
cephalitis plague. It has therefore been called a “ trailer”’. Its
greatest incidence is in the spring, especially during the month
of February. It is not known what particular factor of warfare
predisposes to the ailment, but Dr. Browning of Brooklyn has
drawn attention to the fact that many of the patients have, for
many months preceding their illness, been subjected to abnormal
fatigue, and especially to insufficient sleep.
Among the victims males preponderate to a slight extent, and
the disease occurs at all ages from the day of birth to old age.
Pregnant women are said to be exceptionally liable—also doctors.
468
ENCEPHALITIS LETHARGICA 469
Otherwise professions and trades have no etiological significance.
Jews have shown special predisposition in most countries, and
in tropical areas there is an exceptionally high mortality among
the coloured population. It is often found that the patients
have been already exhausted by some other fever, such as in-
fluenza, pneumonia or searlet fever.
The essential cause of the disease is a filter-passing micro-
organism which—until quite recently—had not been definitely
isolated, but had been cultivated symbiotically with cellular
elements. These are generally obtained from the mouth, for
which the virus has a peculiar affinity, for it can be found there
in healthy carriers. Invasion is supposed to occur vid@ the nasal
mucous membrane. Miss Alice C. Evans of the United States
Hygienic Laboratory claims to have obtained a streptococcus
from the brain of a patient who had died from the disease and
to have passed it through seventeen successive rabbits, all of
whom contracted the disease, quantities of the same micro-
organism being found in the brain of each after death. It appears
that these streptococci vary greatly in size, so that, while most
of them pass through a Berkefeld filter, some grow large enough
to be arrested. Small doses appeared to give a partial immunity
to the animals.
Symptoms.—Encephalitis lethargica varies in severity from
an almost unnoticeable “cold in the head”’ to a malady of the
greatest severity with a wealth of symptoms and physical signs
of an organic affection of the nervous system, perhaps with
hyperpyrexia terminating fatally in a week—or even in a few
hours in status epilepticus. As if this were not bad enough, it
tends to recur in some patients or to leave in its trail a number
of sequel or residua of varying severity, not corresponding with
the severity of the original illness.
In most cases. there is initial headache, usually occipital,
followed by a moderate rise in temperature and a thickly-coated
tongue. The fever lasts until the end of the illness, which may
be weeks, months or even, in one case (Lhermittés), two years
afterwards. Usually it lasts about three weeks.
The characteristic symptom responsible for the names given
to this disease is lethargy or sleep. This is nearly always present,
so that the patients have to be awakened for meals or even fall
asleep during meals. In some cases the sleep is deep enough to
be called coma, and the patient has to be tube-fed.
The brunt of the illness is borne by the cerebrum and mid-
brain. Thus there are usually signs of oculomotor paralysis,
470 MIND AND ITS DISORDERS
such as divergent strabismus with diplopia, ptosis (unilateral or
bilateral), nystagmus and loss of the pupillary reflex. Much more
rarely, other cranial nerves are more or less affected, especially
the fifth, sixth, seventh and twelfth.
The muscles are generally hypotonic with loss of the tendon |
reflexes, but sometimes the limbs are spastic with increased knee-_
jerks. In yet other cases there is a typical flexibilitas cerea
(catalepsy). A curious phenomenon not uncommonly seen is
twitching of muscular fasciculi; sometimes it is so slight that it
has to be looked for, in other cases it may be strong enough to
move the limb.
Hemiplegia may occur with or without aphasia, also with or
without hemianesthesia. More rarely there is paraplegia or a
monoplegia, and difficulty of articulation is not uncommon.
Apart from such cases sensation appears to be normal in
milder forms of the disease, but some peripheral analgesia is
usually associated with profound lethargy in normal sleep.
The superficial reflexes may be unaffected, but quite frequently
the abdominal reflexes cannot be elicited, and the Babinski feet
or toe sign may be present. The tendon reflexes are rarely
quite normal; the knee-jerks may be either exaggerated or, more
rarely, absent.
Of the organic reflexes many are liable to disturbance, such as
difficulty of swallowing, attacks of dyspnoea, hiccough and reten-
tion of urine. The last should always be looked for, and the
physician must not be deceived by an overflowing full bladder.
Salivation may be excessive, and profuse sweating is often a
striking symptom.
The other systems are rarely affected, but the following lesions
and symptoms have been noted:—inflammation of the salivary
glands, epidemic hiccough, obstinate constipation (very rarely
diarrhcea), hamatemesis and melzna, polyuria, herpes febrilis
and herpes zoster.
Sequele.—The name of these is legion. In some cases these
follow immediately after the acute illness, but more frequently
there is an interval which may be as long as six months.
Taking them more or less in order of frequency, the commonest
is the Parkinsonian syndrome, which is indistinguishable from
paralysis agitans except that it appears earlier in life. I have
seen it as early as seven years of age. If there is any difference,
I would be inclined to say that the tremor tends to be less than
in paralysis agitans, but the general disability much greater,
having regard to the duration of the malady. It may also be
SEQUEL& OF ENCEPHALITIS LETHARGICA 471
complicated by one or more of the other sequel, the commonest,
perhaps, being excessive salivation (sialorrhcea).
Involuntary movements of various kinds may occur. Perhaps
the most characteristic of these are rhythmical jerkings of one
or both shoulders or hips. In one of my cases (shoulder), these
were synchronous with the heart beat.
Sometimes the movements are myoclonic in character or,
quite as commonly, athetoid or choreiform. In some cases they
are quite violent and even painful. Cataleptic flexibilitas cerea
(often erroneously called katatonia in the textbooks) may appear
as a late manifestation. Torticollis has also been recorded.
Partial paralysis, similar to those occurring during the acute
illness, are sometimes seen. When hemiplegic in distribution,
the hemiplegia tends to be of the crossed type, as in lesions of the
brain stem. The optic thalamus cases are characterized by
weakness of one side of the face for volitional movement and of
the other side for an involuntary smile.
Other physical residua are abnormal obesity, atrophy of the
genitalia, hyperidrosis and ichthyosis, hurried respiration alter-
nating with apnoea and tics of respiration.
Mental Sequele.—These are very rarely of such a nature as to
necessitate certification. When they do, in my experience they
are invariably of a confused type, with or without excitement,
depression or stupor. It is, however, extremely common for
chronic nervous exhaustion (acquired neurasthenia) to supervene,
the patients being incapable of sustained effort of any kind, and
therefore unemployable. Bad temper is sometimes reported in
these cases, but this is probably but a normal reaction to being
bullied by their relatives for laziness, which they have not recog-
nized to be pathological.
In children the most striking and characteristic changes occur
in the moral sphere. They become disobedient and uncon-
trollable, and take to stealing, lying and savagery. They make
brutal attacks with weapons on their brothers, sisters or pet
animals of the house. These cases are now becoming so frequent
that the Metropolitan Asylums Board is setting up special institu-
tions to deal with them.
. Morbid Anatomy.—tThe only characteristic lesions are found in
the central nervous system, and are most marked in the mid-
brain and pons. The meninges are cedematous, and in some
cases thickened. The centrum ovale is unduly wet, the puncta
cruenta are well marked, and the ventricles may be dilated.
Microscopically the smallest bloodvessels show a perivascular
472 MIND AND ITS DISORDERS
‘ cuff” of infiltration by cells with round, deeply stained nuclei.
There are also small scattered masses of plasma cells, lympho-
cytes, and perhaps polynuclear cells in the nervous parenchyma.
There are also the usual signs of neuronal degeneration. In the
cerebral cortex the “elective zone’’ (as authorities style it) is
the hippocampus. )
Prognosis.—The mortality varies between 20 and 50 per cent.,
death occurring at any time during the first month, but usually
in the third week of the disease. Among those who survive the
acute illness, at least two-thirds have some sequel or residua
from which they never completely recover.
Treatment.—During the acute stage the patient should, of
course, be nursed in bed. The diet should not be stinted, but
it should usually be of a light, liquid and nutritious nature.
Half a bottle of champagne in the course of the day or an equiva-
lent amount of dilute brandy is to be recommended. When the
stupor is profound or swallowing difficult all nourishment and
medicines must be given through a stomach-tube.
The only specific treatment is to disinfect the mouth, throat
and cerebro-spinal system. The former is achieved by frequent
washing, gargling or swabbing of the mouth and throat with a
solution of potassium permanganate (I in 100), and the latter by
internal administration of—
Hexamine, . bs ee is tte gies,
Acid sodium phosphate .. +7 se + Pl eve
Water are a5 ie a is oo he
Every six hours.
As there is every probability that the infection still persists during
the sequelz, these should be treated in the same way.
The physician should be on the look-out for retention of urine
during the acute stage, and a catheter passed if necessary.
For the Parkinsonian rigidity, the best drugs are tincture of
hyoscyamus (or hyoscine hydrobromide) in full doses and injec-
tions of cacodylate of soda, 5 grains on alternate days for about a
month at a time. Dr. Hall of Sheffield recommends full doses
(say 20 minims) of tincture of belladonna three times a day for
this condition, and also for the sialorrhcea which so frequently.
accompanies it. The effective alkaloid in both hyoscyamus and
belladonna is said to be levo-hyoscyamine.
CrlAtLE KS XX.
CHRONIC CORTICAL ATROPHY
(ARTERIOPATHIC AND SENILE DEMENTIAS.)
In this group are comprised a number of cases presenting similar
clinical features and characterized anatomically by cortical
atrophy. In one class this cortical atrophy is due to wasting
of the parenchymatous elements as the result of senility, prema-
ture or otherwise; these have lived their day and they disappear
by a process of abiotrophy. In another class the disappearance
of the cortical elements is due to malnutrition of the cortex from
degeneration of the cerebral arteries, these having become
sclerosed as a result of alcoholism or plumbism, as a sequel to
some specific fever or in association with cirrhosis of the kidney
(arteriosclerotic insanity). This form of dementia is usually
encountered among persons who have attained at least their
fifty-fifth year; but it is occasionally met with as early as the
fourth decade in consequence of past syphilis causing cerebral
endarteritis or atheroma (syphilitic dementia). I have also met
with a case of this nature resulting from chronic sulphonal
poisoning for sixteen years, the patient being only fifty years
of age at the time of the consultation.
Physical Signs.—Apart from hemiplegia, due to cerebral
thrombosis and softening, which is liable to arise in most of
the above conditions, the physical signs associated with arterio-
pathic dementia are those of the disease which has given rise to
the arteriopathy. In old age, for example, there is loss of flesh,
especially in the limbs and face, the face becoming wrinkled
and the eyes sunken. There is fatty degeneration of the upper
and lower margins of the cornea (arcus senilis), dimness of vision
due to slight opacity of the ocular media, weakness of accom-
modation, myosis and diminution of the pupillary reaction to
light. Fibrosis of the tympanic membrane is responsible for
some difficulty of hearing in general and perhaps for the failure,
which I have noted in many cases, to hear the high-pitched
notes of a Galton’s whistle. There is general muscular weakness,
473
474 MIND AND ITS DISORDERS
often accompanied by tremor on movement. The old man is
unable to stand upright and this, as well as a certain amount
of flattening of the intervertebral discs, leads to diminution of
stature. The superficial and deep reflexes are usually diminished.
Urine is passed with excessive frequency, the urinary passage
being obstructed by an enlarged prostate and the bladder thereby
distended. Prostatic enlargement occurs in about 34 per cent. —
of men over sixty years of age. In all cases of general arterio-
sclerosis, both young and old, the urine is abnormally abundant
and dilute.
In the syphilitic cases, there is usually some physical sign of
the patient having previously contracted that disease, such as
psoriasis palmaris, pigmentation of the skin of the leg in the site
of a former ulcer, scarring of the fauces from previous ulceration,
enlargement of the glands behind the sterno-mastoid, or ocular
palsy of some kind. Some of the patients suffer from tabes and
are liable to be mistaken for general paralytics; the differential
diagnosis is sometimes rendered exceptionally difficult by the
occurrence of epileptiform and apoplectiform attacks. The
pressure of the cerebro-spinal fluid is often raised and there may
even be a mild leucocytosis with presence of globulin.
Mental Symptoms.—Although, owing to the multitude of
causes of chronic cortical atrophy, the physical signs met with
in these patients may be diverse, there is great uniformity in the
mental symptoms.
The earliest stages are characterized by headache, attacks of
giddiness, somnolence during the day and insomnia at night.
The patient is slow in thought and movement, and emotional
reaction is excessive so that he becomes irritable or perhaps
unduly sentimental. A paranoid condition sometimes develops
with delusions of neglect and persecution and often with hypo-
chondriacal delusions. Apart from the dimness of vision and
difficulty of hearing due to local causes above mentioned, there
appears to be no diminution of sensation in any department,
even in most advanced cases.
As the disease progresses 1mperception occurs and is demon-
strated by the patient’s failure to distinguish between blues and
greens and by his inability to take in the meaning of simple
sentences or of pictures.
Later he becomes unable to recognize objects or at least to
give them a name. He is disorientated in time and place, does
not know where-he is, has no idea of his age and is unable to
say what year itis. In typical cases hallucinations do not occur.
CHRONIC CORTICAL ATROPHY 475
There is poverty of tdeation and lack of coherence in the train
of thought, any chance percept being sufficient to divert the
patient’s purely instinctive attention; voluntary attention is
practically obliterated.
Failure of memory is noticeable from the first. Difficulty of
remembering proper names marks the beginning of the amnesia,
which is slowly progressive, the memory subsequently under-
going dissolution according to the laws laid down on pages I41-2.
The cortical perception centres are incapable of retaining new
impressions and the patient lives in the past. He forgets where
he places things and perhaps accuses others of having stolen
them.
Motor and agnostic apraxia occur in this disease more con-
stantly than in any other form of mental disorder. In the
early stages the patient makes mistakes in his ordinary work,
later he loses the faculty of using objects correctly. Ideational
inertia is common; for example, if the patient be shown a foun-
tain-pen, he will take off the cap (action correct); if next he
be shown an ordinary pencil, he may try to do the same thing
with it (action incorrect owing to inertia of ideation). This
phenomenon is sometimes to be observed in letters written by
these patients, the same phrase or sentence recurring from
beginning to end (vide letter on pages 161 and 162).
Flexibilitas cerea may sometimes be noted.
With imperception agnostic apraxia occurs as a matter of
course; the patient is unable to use an object correctly because
he does not recognize its true nature.
The conduct is characterized by restlessness without energy
and undue tendency to fatigue. There is progressive loss of
control of the emotions and instincts. These patients may
laugh, weep or show irritability on very slight provocation.
In a previous chapter it has been remarked that loss of control
of the instincts occurs in the reverse order to that in which
control of them is attained in early life, roughly in the reverse
order of their evolution. In senile dementia control of the
sexual instinct is lost disproportionately early, partly on account
of some local irritation caused by prostatic enlargement. This
is of considerable medico-legal importance on account of the
frequency with which old men, hitherto unsuspected of mental
disorder and bearing a spotless reputation, are suddenly arraigned
before a criminal court for a sexual offence, often of a perverse
character. There is a stage in the decay of the old man during
which the instinct of possession shows itself in an exaggerated
476 MIND AND ITS DISORDERS
form. He perhaps marries a girl of twenty to gratify his sense
of power; and as regards his worldly possessions, he becomes
abnormally canny and suspicious lest others should attempt to
deprive him of them, but lacks the enterprise necessary to
increase them. Similar loss of control, paralysis of volition, —
occurs in the arteriopathic cases. Dissolution steadily pro-
gresses; the patient may take to collecting rubbish and, in his
second childhood, return to the age of make-believe and play.
Finally, the instincts themselves disappear, the patient becoming
wet, dirty and bedridden like a general paralytic.
The judgment is defective, but there is no great tendency to
the formation of delusions. Any delusions which arise are
directly dependent on the loss of memory.
rege Deoriat
WNAe yo pena The shi bpene ‘
Pend me abo Srwe cough dnohe
- any Kerk tf stele you Mary be ahie
la gue Thar Lye VieZ -
FIG. 73.—SENILE WRITING.
The infantile desire for sweets is worth noting.
Throughout the whole course of the disorder insomnia at
night is the rule and is accompanied by motor restlessness. In
the daytime, however, these patients are peculiarly liable to drop
off to sleep in the midst of a conversation and even when actually
speaking.
There is no disturbance of articulation, but the content of
thought is so disjointed that speech may be incoherent and
senseless. Perseveration is common, the patient repeating the
same remark over and over again. ,
Diagnosis.—The disease which most closely resembles chronic
‘ cortical atrophy is general paralysis; not that the latter is so
liable to be mistaken for the former as the former for the latter.
Difficulty of diagnosis is most likely to arise among syphilitic
cases, especially among those presenting symptoms of tabes.
DIAGNOSIS OF SENILITY Ag.
Mistakes are to be avoided by attention to detail. Tertiary
manifestations are rare in general paralysis, but common in
syphilitic dementia; in general paralysis, attacks of paralysis
are transitory, in chronic cortical atrophy they are permanent;
in chronic cortical atrophy, the dysarthria characteristic of
general paralysis is wanting. The writing shows evidence of
hand tremor in both classes of patients; but the senile dement
does not omit and repeat words and letters as the general para-
lytic does. Moreover, senile tremor does not affect the tongue.
The knee-jerk is increased in general paralysis in a characteristic
manner, except in the tabetic cases; whereas it is diminished
in chronic cortical atrophy. Lastly the disturbances of per-
ception, orientation, memory and conduct are much more pro-
found, relatively to the physical condition of the patient, in
chronic cortical atrophy than in general paralysis. Delusions,
on the other hand, are more common in general paralysis.
Acute confusional insanity, which may closely simulate chronic
cortical atrophy, is to be differentiated by the presence of hal-
lucinations and peripheral anesthesia.
In some patients who are subject to attacks of melancholia,
chronic cortical atrophy is liable during its early stages to simu-
late that disease. In such cases special attention should be
directed to the state of the memory.
No sharp line can be drawn between ordinary senile dotage
and senile dementia. The normal mental deterioration incident
upon old age is itself early senile dementia. The medical man
is likely to be asked in a court of law at what stage of senile
decay a man is to be regarded as insane; but the question cannot
be answered and it is best to allow each case to be considered
on its own merits.
Prognosis.—This form of dementia is indicative of an extensive
and progressive organic degeneration of the nervous system;
there is consequently little hope of amelioration of the patient’s
condition by treatment.
In the syphilitic cases the disease may be arrested, but not
cured, by the administration of mercury and potassium iodide;
in the others death may be expected in five to ten years. Potas-
sium iodide appears to be beneficial also in the non-syphilitic
cases. I use it therefore as a routine medicine for all patients
suffering from chronic cortical atrophy. In some of the senile
cases dissolution takes place within a few months.
Pathology.—The most striking feature at an autopsy on one
of these patients is the great wasting of the brain.
478 MIND AND ITS DISORDERS
The dura mater is firmly adherent to the skull-cap and patchy
meningitis interna hemorrhagica is sometimes found. The pia
arachnoid is thickened and cedematous and there is an increase
of Pacchionian bodies. The membranes may be stripped from
the cortex with unusual facility.
The cortex is thinner than natural and the convolutions are
atrophied. The whole of the brain is wasted and not uncom-
I'IG. 74.—SENILE BRAIN FROM A PATIENT FORMERLY OF EXCEPTION-
ALLY HIGH INTELLECT.
Under observation he showed marked apraxia and agnosia. Note the
atrophy of the frontal lobes. (The asymmetry is only apparent,
being due to post-mortem change while the brain was lying in
formalin.)
monly weighs less than 40 ounces; but the atrophy is most
marked in the frontal lobes, especially in their lateral aspect.
As a result of this atrophy there is great excess of cerebro-spinal
fluid, the ventricles are dilated and the pia arachnoid, which
is usually thickened and studded with large Pacchionian bodies,
is cedematous. The pia arachnoid may be readily stripped
from the convolutions without tearing them.
PRESBYOPHRENIA 479
In abiotrophic cases the wasting of the brain is due to primary
atrophy of the neuronal elements of the cortex; in the arterio-
pathic cases the neuronal degeneration is due to malnutrition
caused by thickening of the cerebral arteries.
There may be extensive degeneration of the bloodvessels
throughout the body, but the cerebral arteries suffer most. The
thickening is of the inner coat in the syphilitic, of the middle
coat in the arteriosclerotic cases. Miliary aneurysms may
often be detected by manipulating portions of the brain in a
stream of running water and subsequent microscopical ex-
amination. Following on the arterial degeneration there are
frequently small foci of softening in the Rolandic areas of the
cerebrum and around the smaller vessels of the basal ganglia,
especially of the lenticular nucleus. These frequently present
on section a spongy aspect from dilatation of the periarterial
spaces (état criblé). This is probably the cause of the tremor.
Fischer describes certain “ gland-like ’’ enlargements on the nerve
fibres in such necrotic foci, which he regards as peculiar to this
disease. Microscopic examination of the cortex reveals ex-
tensive, at first pigmentary, degeneration of the nerve-cells,
best seen in the motor area, with consequent degeneration of
motor fibres of the corona radiata. Accompanying these changes
there is extensive proliferation of neuroglia, especially in those
parts where the felt-work is normally dense; for example, just
beneath the ependyma. Alzheimer describes a_ perivascular
gliosis with destruction of nervous tissues round the vessels. The
cortex is infiltrated with spider-cells (scavenger-cells of Bevan-
Lewis). Macroscopically this sometimes gives rise to a slightly
frosted appearance of the floor of the fourth ventricle. Small
cysts may be found in the choroid plexuses.
Microscopic examination of the medulla and spinal cord reveals
similar changes, degeneration of motor cells and fibres. There
is even some degeneration of the myelin sheaths of the peripheral
nerves.
The kidneys being usually cirrhotic, the renal cortex is thinner
than natural and may contain a few cysts.
PRESBYOPHRENIA.
This is rather a rare mental disorder occurring in the senile
or presenile period and usually regarded as an involution; but
the symptoms and signs are so suggestive of some form of chronic
intoxication that it is doubtful whether presbyophrenia is not
480 MIND AND ITS DISORDERS
incorrectly named and to be described as an independent disease.
The reader will notice its remarkable resemblance to poly-
neuritic insanity.
Etiology.—As a rule no cause of presbyophrenia can be dis-
covered; but a few cases date their origin from some acute illness, ~
such as influenza, bronchitis, gastro-intestinal catarrh or a head
injury. I have not seen the disease in any patient under fifty-—
five years of age. 3
Symptoms.—Sensation is usually unaffected, but in some
patients one side of the body is less sensitive than the other.
Perception is profoundly disturbed. The patients mistake
identities and are completely disorientated in both place and
time. They do not know where they are and, even after they
have been in an asylum for some months, quite readily accept
the suggestion that it is a church, a theatre or their own home.
They have no idea of the date and, if they attempt to guess
what year it is, may be more than fifty years out. Often they
cannot tell whether it is morning or evening, winter or summer.
Yet these patients are mentally accessible and can follow an
ordinary conversation fairly well.
Similarly there is gross disturbance of memory. They forget
almost immediately what they have only just heard, seen or
done unless it has excited considerable emotion. Often they
cannot make even an approximate guess at their own age,
remember the death of their parents, know how many children
they have or tell their names. Yet they can remember some
things of importance in their everyday life, such as the price of
food, how to prepare certain dishes, and such like.
There are illusions of recognition and memory. The patients
greet strangers as old friends and recognize places as familiar
where they have never been before. Similarly there is a tendency
to confabulation ; they relate incidents which have not happened
and believe them to be true (paramnesia)—that they have just
come from a banquet, received a visit from their parents, attended
a wedding yesterday etc.
Presbyophreniacs are usually amenable to suggestion and
persuasion, again like patients suffering from polyneuritic
insanity.
They have fairly good insight as a rule and sometimes show
distress about their disorder of mind. Indeed, they will often
make absurd excuses for their loss of memory or apparent
ignorance. Such patients usually have no delusions; but a
few complain of persecutions of various kinds, such as being
ALZHEIMER’S DISEASE 481
robbed, poisoned or altered by some mysterious means. Hallu-
cinations practically never occur.
These patients are liable to drop off to sleep at all times of
day; but at night they are restless and often busy packing up
their bedding in a corner of the room. Their conduct during
the day, on the other hand, is fairly normal.
Physical Signs.—A few presbyophreniacs show some signs of
peripheral neuritis, such as pains along the nerve trunks, wasting
of muscles and loss of the tendon reflexes; but such cases are rare.
Headache is a common complaint. The pupils are small,
sometimes unequal, and they react but feebly to light.
There is general motor weakness with a shuffling gait and
tremor of the senile type is usually present. Sometimes the
weakness is more marked on one side than on the other.
Morbid Anatomy.—The brain is wasted and microscopically
shows the usual senile changes; but there is also extensive fatty
degeneration of the cortical nerve and glia cells. The nerve-
cells are ultimately destroyed without much disturbance of the
kinetoplasm, so that their fibrillation is often more easily ob-
served than in a normal specimen. Marinesco and others
describe sclerotic “‘ plaques ’’ or nodules in various parts of the
cortex. Some authorities regard them as normal in brains of
persons over fifty years of age, but much more abundant in
senile dementia. The nodules measure 15 w to 804 in diameter
and each consists of a central nucleus which is readily stained,
an intermediate zone of radiating filaments and an outer layer of
doubtful nature.
ALZHEIMER’S DISEASE.
Although this rather uncommon malady has also been regarded
as a morbid variety of involution it is probable that it will
ultimately have to be given the status of an independent disease,
not only because of the severity and large number of physical
signs of nervous disease, but also because cases have been recorded
as occurring as early as thirty-one, thirty-three and forty years
of age.
Symptoms.—During the first year or so of the disease there
is gradual mental deterioration with poverty of ideation and
general weak-mindedness. Ultimately, perception is lost even
to a more profound degree than in presbyophrenia, so that the
patients are unable to comprehend what is going on around
them; much less can they take in the meaning of a picture,
however simply and clearly it tells its story. There is complete
31
482 MIND AND ITS DISORDERS
disorientation, to such an extent that the patients can only
make feeble and futile attempts to find their way even on
familiar ground. Auditory and visual hallucinations are fairly
common. |
There is also profound amnesia, not only for ordinary events ©
of both recent and remote date, but also for occupations to
which the patients have been accustomed for many years.
They appear to live in a world of their own, chatter, mutter,
laugh and sing to themselves. They are dirty in their habits
and perform all sorts of apparently meaningless actions, such
as running aimlessly about, polishing the walls or floor of their
room with spittle, picking at the bedclothes and so forth.
Apraxia is an early symptom, but the most striking disorder
is that of speech. At first the sentences hang together fairly
well, but there is a tendency to repeat individual syllables and
words several times before getting on with the sentence, some-
what like stammering. Ultimately the speech is nothing more
than a repetition of apparently meaningless syllables. Doubt-
less the patient is trying to say something, but he is incapable
of appreciating the complete failure of his efforts.
Emotionally these patients are dull and apathetic.
Physical Signs.—These are all motor. Epileptic convulsions
are common, general tremor is fairly constant and twitching of
individual muscles occurs.
A form of bulbar paralysis occurs with characteristic difficulty
of articulation and swallowing, with flabby paralysis of the
tongue. There is also an amyotrophic spastic paralysis of the
limbs and trunk with exaggeration of the tendon reflexes.
Finally the patient becomes bedridden somewhat like a
general paralytic and dies either from marasmus or some inter-
current disease.
Morbid Anatomy.—The brain is atrophied and presents the
general appearances described on pp. 478-9. It was in these
cases that Alzheimer first discovered the plaques mentioned
on p. 481, but it has since then been found that they are almost
a normal feature of senile brains. There is fatty degeneration
of the nerve-cells as in presbyophrenia; but the appearance of
the intracellular neurofibrils is rather different. They are
thickened, fused together and formed into loops or whorls.
Spider-cells are present in large numbers, as in general paralysis.
Treatment.—In organic diseases of this nature the treatment
can but consist of careful and kindly nursing with attention
to the patient’s physical requirements and the administration of
TREATMENT OF SENILE CASES 483
mercury and potassium iodide in syphilitic cases. Potassium
iodide is very often beneficial in arteriosclerosis also. Alcohol
and tobacco should be avoided. The latter appears to be
especially harmful to some of these patients, producing great
confusion for an hour or so after smoking.
The most important question which arises in cases of senile
dementia is whether asylum treatment is necessary or not. To
the author it appears desirable that considerable effort should
be made to retain the patient in his own home, for it is surely
a sad and serious thing that an old man should end his days,
separated from home ties, in an institution for the insane. Of
course every case must be considered on its own merits; un-
fortunately the difficulty of nursing these patients at home is
often insuperable and they are after all better off in an asylum.
Any special tendencies to sexual aggressions or to suicide usually
necessitate asylum sequestration and care.
CHAE A oe
MENTAL DISORDER ASSOCIATED WITH CERTAIN OTHER.
NERVOUS MALADIES.
CHOREA.
THE characteristic feature of chorea is the occurrence of in-
voluntary, irregular, sudden and somewhat jerky movements,
muscular weakness and inco-ordination of voluntary movement.
A detailed account of so common a disease would be out of place
in a work of this nature; we therefore proceed at once to the
consideration of the
Mental Symptoms.—Most observers are agreed that cutaneous
sensation is unaffected in uncomplicated chorea. Similarly
hearing, vision, taste and smell are normal.
The only disorder of perception is the somewhat rare occur-
rence of hallucinations, usually of vision, rarely of other sense-
modalities.
Difficulties of ideation (the revival of memory-images) is one
of the most striking symptoms. If, for example, a choreic
patient be asked to name all the animals he knows of, he fre-
quently cannot mention more than three and I have known
one unable to remember any other animal thanahorse. Another,
a girl of twelve, whom I asked to enumerate all the birds she
could remember, could get no farther than a robin, cock-robin and
robin redbreast. On the other hand, associative memory is fairly
good for remote events, but it may be defective for recent events.
Association of ideas is apt to be of the scatter-brained variety.
All these disorders of ideation are due to lack of attention.
The spontaneous involuntary movements and defective co-
ordination render the attitude of attention impossible; the
organism cannot be favourably adjusted for the reception or
revival of sensory impressions. For the same reason the child
is unable to learn lessons.
The emotional tone is variable, being mostly determined by
the attitude into which the patient is thrown by the choreic
movements; he is by turns angry, fearful, fretful, capricious
and irritable.
434
HUNTINGTON'S CHOREA 485
Movement being entirely uncontrolled and dominated only
by the caprice of the disease, volition is defective in severe
cases.
Various forms of insanity may arise episodically during the
course of chorea. In such cases the choreic movements rapidly
cease and become replaced by those characteristic of the par-
ticular form of mental disorder which is present. In view of
the frequency of chorea, the rarity of its occurrence as an ante-
cedent of certifiable mental disorder and the variable nature
of the insanity which occurs as a sequel to chorea, no direct
relationship can be acknowledged to exist between chorea and
insanity. Excluding cases of Korssakow’s disease induced by
arsenical treatment, the author has seen cases of mania, melan-
cholia, exhaustion psychosis and dementia przecox (katatoniac
stupor) following directly on acute chorea, four cases out of
some thousands.
HUNTINGTON’S CHOREA.
This rare disease, which has no relationship to the form above
described, is a chronic incurable chorea which begins usually
between thirty and forty years of age and is apt to occur in
several members of the same family. It appears to be much
more frequent in the United States of America than elsewhere.
The movements are slower than those of Sydenham’s chorea.
They affect the face, causing grimaces; the tongue, causing
difficulty of articulation; the hands, interfering with the patient’s
writing; and the lower limbs, causing an occasional drunken-
looking lurch in his gait. In attempting to do things the
muscular activity commonly overshoots the mark.
Mental Symptoms invariably occur in association with this
disease. At first the patients are irritable; later, depression of
the melancholiac type dominates the clinical picture. As the
disease progresses the capability of reviving memory-images is
lost, as in Sydenham’s chorea; associative memory then becomes
impaired and ultimately lost. Dr. Farquhar Buzzard’s patient
whom I had the advantage of examining at a clinical meeting of
the Neurological Society had well-marked imperception. He
was unable to name at sight fairly common objects and he could
not apprehend the meaning of other than simple sentences
(agnosia). Agnostic apraxia, of course, was present and I
thought that there was, in addition, some motor apraxia.
All the intellectual faculties undergo progressive deterioration
and the patient, after twenty or thirty years, becomes reduced
486 MIND AND ITS DISORDERS
to a condition resembling the terminal stage of general paralysis.
Some authors, including Kraepelin and Binzwanger, have even
gone so far as to regard Huntington’s chorea as a form of general
paralysis. This view receives some degree of support from the
post-mortem appearance of the brain, chronic leptomeningitis
being present with adhesion of the pia mater to the cortex; but
the absence of spider cells and plasma cells as well as the heredi-
tary nature and invariably chronic course of the disease indicate
an essential difference between the two disorders.
Jelliffe and White, in their “‘ Diseases of the Nervous System ”’,
say that “ the disease behaves as a complex in which age, motor
disturbances and mental defect behave more or less independently
of one another. When all three factors combine, the result is
Huntington’s chorea ”’
PARALYSIS AGITANS.,
This disease is of particular interest to the psychiatrist on
account of its resemblance to melancholia. In both there is a
general attitude of flexion, in both there is proximal rigidity
and in both there is a tendency to overaction of the muscles
controlling movements at the small joints.
In the chapter on melancholia the author has shown how
misery is the result of this attitude. Similarly in paralysis
agitans this attitude of misery induces a feeling of depression,
at least in the later stages of the disease when the physical signs
are well marked. There is often a vague sense of impending
harm, sometimes amounting to suspicion. I have known a
hospital patient become greatly agitated whenever there was a
change of house physicians, knowing full well that some new
drug would be tried on him, and fearing the worst.
Like many melancholiacs these patients always feel warm and
do not like to be near the fire. There is no Joss of sensation.
Perception is liable to be impaired in long-standing cases
and hallucinations of hearing sometimes occur. There is re-
tardation of the train of thought and recent memory is some-
times impaired in the later stages of the disease. The patients
occasionally threaten suicide, but I have never heard of this
threat being carried out.
Diagnosis.—It will be remembered that a similar symptom-
complex commonly occurs after encephalitis lethargica, and it is
customary to diagnose this disease as having occurred whenever
we meet with a condition resembling paralysis agitans in a person
PARALYSIS AGITANS 487
under fifty years of age. When we find it in a patient engaged
in such trades as paint-, varnish-, enamel- or linoleum-making it
may be due to chronic manganese poisoning.
Jelgersma has described degeneration of the lenticular bundle
of Forel and of the striothalamic fibres in two cases of paralysis
agitans, and Hunt (Brain, 1917) ascribes the disease to degenera-
tion of the motor cells in the globus pallidus. A lesion in this
region has previously been suspected by neurologists on account
of the coarse involuntary character of the tremor in this malady
and there is little doubt that the physical basis of the disease
is somewhere in the neighbourhood of the lenticular nucleus.
Why on earth such an archaic part of the cerebrum should be
such a common site of degeneration seems rather a mystery.
Lundborg ascribes it to hypersecretion of the parathyroids.
However, arteriosclerosis is a constant feature not to be neglected
in attempting to establish the pathology.
Treatment.—Probably every sedative under the sun has been
tried for relieving the distress of paralysis agitans. Of these I
have found trional, Cannabis indica and hyoscyamus the most
useful.
CHAPTER XXII.
MENTAL DISORDERS OCCURRING IN ASSOCIATION WITH
VISCERAL DISEASE.
Ir is almost a truism that the higher functions of the brain
are liable to be perturbed whenever the functions of the menial
viscera become disordered through disease. If large portions
of the lung be destroyed, the brain suffers from deficient aeration
of its nutrient medium, the blood; in uncompensated heart-
disease the brain is affected as much as, or more than, other less
delicate organs by the inefficient circulation of the blood; if
the kidneys fail to excrete toxic products, the brain must be
injured by the effects of the retained poisons. These facts have
long been recognized and in a bygone age, when the relation-
ship was ill understood, mental disorder associated with visceral
disease used to be called “‘ sympathetic insanity ’’. Since those
days our knowledge of the relationship has been advanced by
numerous investigators. We have already dealt with the
delirium of fever, the post-febrile exhaustion insanities and the
insanities associated with disease of the endocrine organs. In
this chapter we have to consider the mental condition of patients
suffering from phthisis, heart-disease, kidney disease and de-
rangement of the digestive system.
The most interesting contribution to this subject is con-
tained in Dr. Head’s Goulstonian Lectures for 1go1. The
observations recorded in those lectures have been neither con-
firmed nor refuted by any subsequent observer, but there is no
reason for doubting them. Dr. Head reports the occurrence of
hallucinations of vision, hearing and smell in cases of phthisis
and heart-disease. Hallucinations of vision are the most
frequent; they usually take the form of a figure standing at the
foot of the bed and are said to be lacking in colour. The halluci-
nations of hearing do not take the form of voices; they are usually
knocks or taps, bells, footsteps or heavy breathing. The smell
hallucinations are of decaying matter, something burning, an
earthy smell or the smell of gas. The patients are also liable
to attacks of depression or suspicion. It is further stated that
488
PAIN CAUSING HALLUCINATIONS 489
all these mental symptoms arise in association with severe or
prolonged pain resulting from disease of the viscera and referred
to the body-wall. In Dr. Head’s series of cases the symptoms
occurred in phthisis, aortic regurgitation, aneurysm and dilated
aorta, mitral regurgitation, combined aortic and mitral disease
and in adherent pericardium. They do not occur in the absence
of pain, e.g., in those cases of valvular disease in which the first
sound is abolished or in cases of phthisis in which destruction of
lung tissue progresses so rapidly as to destroy the pulmonary
nerve-ends. Nor do these mental phenomena occur in association
with the pain of pleurisy, the explanation given by Dr. Head
being that this pain arises in the body-wall itself and is not a
referred or reflected pain. It is obvious, in the light of our
present knowledge, that all these symptoms are due to states of
exhaustion and fever, which we have recognized to be especially
provocative of hallucinations.
It is further pointed out that pain referred to the abdomen
is more liable to cause mental depression than pain in any other
region. Hence it is found that the pain of aortic disease, which
is referred to the upper part of the chest, is less frequently
associated with mental depression than that of double mitral
disease which is referred to the upper abdominal areas.
Similarly with phthisis. In the early stages, when the disease
is limited to the apices of the lungs, the patient is cheerful and
hopeful of recovery (spes phthisica); but when the disease in-
vades the lower lobes and the pain is referred to the abdomen,
he becomes depressed and is fearful of impending harm. Later
he becomes suspicious, thinks that others are talking about him
and that the nurses do not like him and are inclined to neglect
him. With inexperienced nurses this mental attitude is liable
to lead to unfriendliness, complaints and even quarrels; but the
phthisical patient’s last days may be made much happier if he
be treated with the tactfulness which nurses are wont to extend
to patients whom they recognize to be suffering from mental
disorder. )
It is interesting to note that exactly the same mental symptoms
occur in cases of tubercular peritonitis, but even in a more
marked degree.
The depression and train of neurasthenoid symptoms associated
with enteroptosis are possibly to be accounted for in the same
way, abdominal discomfort being especially lable to induce a
state of misery and chronic nervous exhaustion.
By the way, many cases of enteroptosis are due to dilatation
490 MIND AND ITS DISORDERS
of the stomach, which allows the colon to fall into the lower part
of the abdomen. Again, many cases of gastric dilatation are
due to anxiety states, the consequent adrenalemia inhibiting
peristalsis and closing the pylorus and possibly the other intes-
tinal sphincters described by Sir Arthur Keith. In such cases
the visceroptosis should be treated as well as the anxiety state, |
because it reacts on the nervous system and treatment of it
frequently relieves many of the neurotic symptoms. A Curtis's
belt and some gastric antiseptic, such as Dimol, give much relief;
but some people recommend a surgical operation.
Adrenalemia is also responsible for the high blood-pressure
occurring in anxiety states. Craig found that a low blood-
pressure is liable to be associated with motor restlessness. In
accordance with this observation we find that attacks of excite-
ment are common in patients whose blood-pressure is low, especi-
ally those afflicted with aortic disease. Similarly in all cases of
heart-disease, When compensation suddenly fails, motor restless-
ness is an almost invariable concomitant. The same symptom
is observed in cases of chronic renal disease when the blood-
pressure suddenly falls as a result either of cardiac failure or of
prolonged diarrhoea. On the other hand, we have all had patients
with a blood-pressure of 250 mm. of mercury or more who are
invariably happy and cheerful; but it must be admitted that
they are usually depressed. I know of no treatment that will
materially reduce such a high blood-pressure and, in my ex-
perience, the life of such patients is destined to terminate within
a couple of years.
Uremia.—There is an acute delirious form of uremia in
which occur many of the symptoms characteristic of acute con-
fusional insanity of toxic origin. There are hallucinations of
vision and hearing and the patient exhibits occupation delirium
in which he is apparently busy at his usual work. There is
difficulty of perception and it is impossible to distract the patient's
attention from his hallucinations; if, however, one succeed in
doing so, it is found that there is difficulty of perception, with
disorientation in time and place. The memory is poor. The
patient is restless and agitated and is liable to localized or general
convulsions.
When psychosis arises episodically during the course of chronic
Bright’s disease, states of depression are more common than
states of excitement, probably on account of the raised blood-
pressure. According to Roubinovitch, Bright’s disease may be
suspected of having etiological relationship to the mental dis-
DIABETES 4QI
order when the following symptoms are present: hallucinatory
confusion; crises of hebetude, somnolence or stupor; cataleptic
phenomena occurring independently of hysteria or, we presume,
of dementia przecox; and convulsions or attacks of coma.
Diabetes.—A relationship between this disease and insanity
has long been recognized. It is not uncommon to find a history
of mental disease among the relatives of diabetics, nor is it
rare to find a history of diabetes among the relatives of the
insane. Moreover, sugar may be detected in the urine of about
I in 400 of the insane (Bethlem cases) excluding cases of true
diabetes.
The author has had eight cases of glycosuric insanity under
his care. Six were cases of depression, of whom one died and
five recovered under the ordinary treatment for diabetes; the
seventh became a senile dement. The eighth case was compli-
cated by alcoholism and was really a case of chronic hallucina-
tory insanity. It is said that in some such patients the sugar
disappears from the urine when insanity supervenes, and re-
appears as soon as recovery from the mental disorder is estab-
lished. In the author’s cases the sugar gradually disappeared
under treatment, complete absence of glycosuria preceding by
a considerable period restoration to mental health.
Gout.—The characteristic irritability of a gouty patient during
an acute attack of his disease is well known. Some gouty
patients are liable to attacks of depression in association with
their attacks of gout. In others, attacks of gout are said to
alternate with attacks of insanity.
Treatment is to be carried out on general medical principles.
CHAPTER xecki ia
IDIOCY AND IMBECILITY.
(AMENTIA OR MENTAL DEFICIENCY.)
THESE are states of arrested or retarded mental development
occurring as the result of some disease or of injury to the child
in utero or during the first few years of extra-uterine life.
For practical purposes it is necessary to recognize that there
are different grades of mental deficiency. The subjects. are
accordingly classified into idiots, semi-idiots, imbeciles, semi-
imbeciles or backward children, and moral imbeciles.
Cretinism is elsewhere described (p. 423).
Etiology.—Neuropathic heredity is regarded by many as the
most important and most frequent cause of congenital weak-
mindedness.
It is said that illness, fatigue and especially drunkenness of
the parents at the time of conception are liable to induce idiocy
in the child, also that disease of the mother during pregnancy,
especially in the earlier months, may lead to a similar result.
Injury to the pregnant uterus, often by ineffectual attempts at
abortion, is often regarded as another potent cause inasmuch as
it is liable to interfere with the nutrition of the foetus. This
last factor is held to be responsible for the frequent occurrence
of idiocy among illegitimate children.
We cannot but be sceptical respecting all these alleged causes
of mental deficiency. The spermatozoa are extraordinarily well
protected by mucus against the toxic products of disease, alcohol
and any other poisons in the blood; and the ovary is not a
particularly vascular organ. After conception, moreover, the
embryo is even more cut off from and independent of the maternal
circulation. Again, so serious an attempt at abortion as to
interfere with the nutrition of the foetus would assuredly in most
cases be very far from ineffectual.
At birth the brain is liable to suffer injury if the child’s head
is disproportionately large or the pelvic brim of the mother
deformed or disproportionately small so that labour is unduly
492
CAUSES OF AMENTIA 493
prolonged. For a similar reason we find that the incidence of
idiocy among first-born children is abnormally great. There is
no doubt that the pressure to which the child’s head is subjected
during the process of birth causes retardation of mental develop-
ment, even in normal cases; for it has been ascertained that
children born by Cesarean section develop much more rapidly
than those born in the natural way. They are months ahead
of the latter before the end of the first year. On the other hand,
the last child of a long series is liable to be weak-minded, the
mother’s strength and nutrition having been exhausted by
frequent pregnancies.
Obstetric manipulations at birth have sometimes been held
responsible for producing an idiot; but it is more probable that
some deformity of the head of the child destined to become
an idiot has necessitated interference on the part of the ob-
stetrician.
That idiocy is twice as frequent in boys as in girls is possibly
to be correlated with the fact that the male head has greater
difficulty in passing the pelvic outlet and is therefore more liable
to injury at birth.
Idiocy may occur as a sequel to some of the acute specific
fevers. It is sometimes ascribed to a series of infantile con-
vulsions: a more correct view of the relationship would probably
be that the convulsions are symptomatic of an already existing
degeneracy or morbid tendency of the nervous system.
Most children who acquire organic disease of the brain during
infancy remain mentally defective. These are cases of infantile
hemiplegia, infantile diplegia, meningitis, encephalitis, cerebral
hemorrhage, meningeal hemorrhage and diffuse or nodular
sclerosis. A few cases are due to congenital syphilis.
Lastly there remains to be mentioned the most important
cause of all, epilepsy, which is responsible for about one-third
of the cases.
The etiology of mental deficiency has also been studied from
a purely statistical standpoint, the investigators having an
enormous amount of material at their disposal and exercising
the greatest care in arriving at their conclusions. These, how-
ever, are extremely divergent; for, on the one hand, Mott con-
siders that mental deficiency is the terminal stage of degeneration
of a family whose progenitors have suffered from the maniacal-
depressive psychosis, dementia praecox etc.; while Rosanoff and
Orr are of the opinion that mental deficiency is not related to
insanity at all, but has hereditary features of its own. Although
494 MIND AND ITS DISORDERS
not above criticism, the writings of Rosanoff and Orr have
proved the more convincing to the present writer and they are
more in accordance with his impressions gained from a much
more limited experience. These American physicians even go so
far as to state that the heredity of mental deficiency is in accord- ©
ance with the Mendelian laws if mental normality be regarded
as a dominant and mental deficiency as a recessive character.
Here again, the evidence they adduce in support of this doctrine
is rather convincing.
Dr. C. S. Myers, the psychologist, has drawn attention to the
fact that some cases are of definite psychotic origin, the child
having developed a psychosis in early life which has interfered
with subsequent mental development.
Physical Signs.—These consist for the most part of the physi-
cal stigmata of degeneration described in the chapter on that
subject. They are numerous and of frequent occurrence in
idiots, rather less numerous in imbeciles; but among both classes
the stigmata occur with greater frequency than among the insane.
Paralyses of various kinds are seen in the organic cases.
Mental Symptoms—Sensation.—One form of idiocy, “ idiocy
by deprivation of the senses’’, is entirely due to the patient
having been either born deaf and blind or deprived of the senses
of vision and hearing by disease in early life. Without special
training such persons are destined to remain mentally deficient
because those windows of the soul through which a normal
person gains most of his experience of the outside world are
permanently closed. These patients are of considerable interest
in that it has been shown by praiseworthy tutors of exemplary
patience that such subjects may attain a fair degree of mental
development through education of the sense of touch alone.
In such cases the senses of taste and smell receive no education
but are used to indicate to the pupil what is to be regarded as
pleasant or unpleasant.
It is to be understood that not all blind deaf-mutes are cases
of “idiocy by deprivation”’, but many exhibit the physical
stigmata of degeneration and show evidence of cerebral as well
as peripheral deficiency: such cases cannot be regarded as
educable.
Deaf-mutism is a condition closely allied to “‘ idiocy by depriva-
tion ’’. Children who are born deaf naturally have no means of
learning their native tongue and the knowledge that is to be
gained thereby; they are therefore destined to become deaf-
mutes. They may, however, be taught the deaf-and-dumb
SYMPTOMS OF AMENTIA 495
alphabet or, better still, lip-reading; and they may then be
educated to such a degree that they scarcely miss the faculty of
hearing. The condition is to be regarded as markedly hereditary
and liable to occur in members of the same family, and especially
in the collateral branches. Deaf-mutism is more prevalent in
goitrous districts than elsewhere and it is three times as common
among Jews as among Gentiles.
Blindness invariably occurs in association with the congenital
form known as “‘amaurotic family idiocy ’’: in these cases the
blindness is not in any way a cause of the idiocy as in “ idiocy
by deprivation ’’, but rather a concomitant symptom of degenera-
tion of the nervous system. All the recorded cases have occurred
in the offspring of Jewish parents. The child goes blind shortly
after birth, the ophthalmoscopic appearances being a white patch
in the region of the macula with a cherry-red spot in its centre.
The process terminates in complete retinal and optic atrophy.
This condition is associated with progressive general weakness,
almost amounting to paralysis, and terminates fatally at about
two years of age.
The disease is liable to occur in several members of one family.
Ireland stated that of twenty-seven recorded cases, eighteen
occurred in twelve families.
Apart from the cases of “‘ idiocy by deprivation ”’ and “‘ amau-
rotic family idiocy ’’, blindness exists at birth or develops shortly
after birth in about 6 per cent. of idiots and imbeciles, usually
as the result of optic atrophy. Spasmodic squints and nystagmus
from errors of refraction and other causes are even more common.
Defects of hearing, taste and smell are much less frequent
than those of vision. Defect of hearing is usually due, not to
a cerebral lesion, but to malformation or disease of the ear
itself. Although anosmia 1s uncommon, many idiots appear to
be incapable of experiencing pleasantness and unpleasantness in
association with odours.
It is said that tactile, painful and thermal sensations are
sometimes deficient in the severest forms of idiocy. I have
not been able to verify this observation. On the contrary,
I have observed that painful sensations (pin-pricks) appear
to be normally appreciated by idiots, but that analgesia of the
distribution described on p. 118 occurs sometimes in imbeciles.
An imbecile girl, aged fourteen, whom I saw at Tooting Bec
Asylum by the kindness of Dr. Beresford, could appreciate
painful sensations in the groin and soles of the feet only. She
was of sufficient intelligence to explain to me that, though she
496 MIND AND ITS DISORDERS
would not care herself to transfix a portion of her skin with a
pin, the proceeding caused her no pain. She had sufficient
mental capacity to be able to say the multiplication table up to
‘HVE times ss
Perception.—The perceptive faculties develop either late or ©
not at all. In some of the severest cases of idiocy in which
there is no loss of sensation the patients never make use of their
senses to gain knowledge of their environment. This is entirely
due to want of development of volitional attention. They see,
but they never look; they hear, but they never listen; cutaneous
sensations are present, but they are not even localized.
Inasmuch as the instincts and emotions are forms of reaction
to percepts it is obvious that these reactions cannot take place
in cases of extreme idiocy. Crying occurs, but this is probably
a medullary reflex occurring as a response to painful stimuli;
it is not a true emotional reaction to a percept.
Severe cases of idiocy may be recognized shortly after birth
when it is found that the infant does not seek or even suck the
breast. The instincts are all late in appearing so that an idiot
child ten years of age may be no further advanced in his develop-
ment than a normal child of ten months. Both, for example,
would be beginning to utter articulate sounds and to walk and
both would still be “‘ wet and dirty ”’ in their habits.
In children from whom the faculty of perception is absent
there is of course no desire to eat or drink; left to themselves
they would die of starvation. Similarly the desire to micturate
or defecate is absent; evacuations of the bladder and rectum
take place reflexly as in spinal paralysis.
Idiots, like normal infants, are nearly always asleep.
In imbecility the faculty of perception approaches the normal.
Instinctive attention is present, but the power to attend volun-
tarily is defective. The emotions and instincts develop normally,
but, volition being weak, they are uncontrolled. Accordingly,
we find, in agreement with the principles laid down on p. 148,
that the imbecile has strong emotions and instincts. He is shy
before strangers, so much so that in many institutions for weak-
minded children it is customary to defer examination for a week
or more in order to allow the patient to get over his shyness
and to become accustomed to and more or less friendly with
the doctor. Imbeciles form strong likes and dislikes and they
are very affectionate towards those to whom they take a fancy.
They are usually gentle and timid and feel punishment acutely.
The instincts, in addition to being uncontrolled, are lable to
—_
SYMPTOMS OF AMENTIA 497
be perverted. Some imbeciles take a pleasure in striking or
otherwise injuring creatures weaker than themselves, in breaking
windows, stealing and indulging their sexual impulses. Lying,
however, is not a common fault, for the imagination as a rule
is not sufficiently developed. They can seldom be taught the
full meaning of the difference between right and wrong; but
fear of punishment is often sufficient to cause them to refrain
from immoralities.
The actions of imbeciles are instinctive impulses, imitative acts
or the carrying out of simple orders. True volitional acts occur
rarely.
Ideation is mostly of the visual type, but many imbeciles and
even idiots can remember musical airs. The train of thought
(association of ideas) is of the scatter-brained variety owing to
defect of voluntary attention. For the same reason associative
memory is always defective.
In many of the lighter grades of imbecility, however, the
subjects show a remarkable memory for figures such as dates.
Many of the “ calculating boys’”’ belong to this class. It is not
known by what mental process they arrive at their results; usually
the faculty disappears if they are taught ordinary arithmetic.
Conception appears to be deficient. In the lighter grades of
idiocy and the severer forms of imbecility the patient can form
an idea, for example, of a chair; having got so far, he is in-
capable of developing the abstract concept of a chair and of
appreciating the difference between one chair and another.
For him all chairs are the same. Much less is he capable of
understanding the meaning of such abstract concepts as space,
truth and virtue.
With such deficiency of the power of abstraction and dis-
crimination it need scarcely be added that the judgment is feeble
and more than liable to be erroneous.
The vocabulary of the imbecile is limited. He has names for
common objects and a few adjectives but very few verbs, so
that he rarely forms sentences. As with the lower classes in
this country, adjectives have to do duty for adverbs. In con-
formity with the egoism characteristic of the imbecile the pro-
noun “‘ me ’”’ looms large.
Difficulty of articulation is common. Lisping occurs in cases
where the hard palate is so deformed that the tongue cannot
be uniformly applied to the roof of the mouth. Stuttering and
stammering are also fairly common. There is often difficulty
in the pronunciation of the gutturals and of the liquids / and +.
32
498 MIND AND ITS DISORDERS
Fic. 75.—R.R., AGED Io YEARS, AND HIS SISTER, T. R., AGED 14 YEARS.
HIGH-GRADE GENETOUS IMBECILES (CAUSE UNKNOWN).
VARIETIES TOF TDIOGY 499
Some of these difficulties may be due to the large size of the
tongue in many patients.
A fair number of imbeciles may be taught to write, but the
calligraphy is seldom good. It is puerile and they usually have
difficulty in performing all the finer movements requiring precise
co-ordination.
Moral imbecility is chiefly characterized by deficient control
of the instincts and a fondness for crime, while considerable
cunning and deceit are usually exhibited to evade detection.
Fic. 76.—HYDROCEPHALIC IMBECILE, AGED II.
The egotism of the moral imbecile is unbounded and he is always
a conceited braggart, a liar too of the first order.
His memory is good and judgment fair. He is clever with his
hands, especially at games, usually musical and often artistic,
but incapable of applying himself steadily to a profession or
trade.
Moral imbecility, properly so called, is invariably accompanied
by a certain amount of mental defect or backwardness in other
ways; but this is always slight. Delinquency may be a symptom
of imbecility; such a case is to be classed as an ordinary
“mental defective’’. The diagnosis of moral imbecility is justi-
fiable only when immoral tendencies far exceed the intellectual
500 MIND AND ITS DISORDERS
x
defect. Not every case of delinquency is to be diagnosed as moral
imbecility. Among the lower orders many children are brought
up among thieves and other criminals; not only have they no
chance of learning right from wrong, they are even taught to
do what is wrong. These are not moral imbeciles. Again, some
otherwise normal young people of the upper classes, brought up
in apparently ideal conditions, find themselves occasionally
impelled to commit petty thefts and other delinquencies—to
their own horror and amazement. These are not moral im-
Fic. 77.—Group OF MONGOLIAN IMBECILES AT THE FOUNTAIN
MENTAL HospPITAL, TOOTING,
No two are related to one another, as might be suspected. [Photograph by
Dr. T. Brushfield. }
beciles; their immorality is determined by some unconscious
motive, some complex which can be unearthed by psycho-analysis
so that the case is cured in about six months or even less. More-
over, in appraising a case we have to take into consideration
the habits of the class to which the delinquent belongs; for
example, I have known a family of the lower orders to laugh
on the occasion of one of their number giving birth to a child
one week after marriage; but this would be no laughing matter
VARIETIES OF IDIOCY 501
to the family of a University professor. Lastly, we have to
recognize that delinquency may be an early symptom of some
psychosis, such as epilepsy or dementia preecox, and other signs
of these diseases should always be sought.
CLASSIFICATION.—The usually accepted classification is that of
the late Dr. Ireland, which is based as far as possible on etiological
and pathological considerations.
Genetous idiocy is the name given to states of weak-minded-
ness due to pathological changes in the brain which have taken
place before birth but cannot in the state of our present know-
Fic. 78.—MICROCEPHALIC Ip1IorT.
Circumference of head—=16 inches.
ledge be diagnosed before a post-mortem examination is made.
Many of the other varieties of idiocy may be of congenital origin,
but inasmuch as a diagnosis of the cerebral lesion can be made
before death they are not included in this class.
Among genetous idiots Ireland included the amaurotie family
idiots and also those known as Mongolian idiots, a large class
presenting many of the physical stigmata of degeneration and
so called because of their facial resemblance to the racial Mongol,
the palpebral fissures sloping downwards and inwards. Epi-
canthus and nystagmus are common. The face and back of the
502 MIND AND ITS DISORDERS
head are flattened. The tongue is abnormally long and often
fissured, but this fissuring is not present at birth. The hands
and fingers are soft and stumpy, their ligaments are lax and the
palms show innumerable lines running in all directions. Their
stature is small, mainly owing to shortness of the legs, and they
exhibit a curiously straight back, while the abdomen is rather
prominent. Their articulation is invariably defective. Mon-
golian idiots are especially liable to a form of mucous diarrhcea
which occurs in the congenitally weak-minded. Dr. Rankine,
a former medical officer of the Earlswood Institution, described
a form of cataract in these patients. The pathology of Mongolism
is unknown; the endocrine system is naturally suspected, but
investigation of it has so far proved negative. Another group
have been called Aztee idiots because of their facial resemblance
to the Aztecs.
Microcephalie idiocy is idiocy existing in an individual, the
circumference of whose head is less than 17 inches (18 accord-
ing to some authorities). The smallness of the head is due to
smallness of the brain and not to premature ossification of the
cranial sutures as was supposed by Lannelongue when he pro-
posed the operation of craniectomy to allow the brain to expand.
This operation was performed on many microcephalic idiots
without effecting a single cure. Indeed in some cases the head
grew smaller as a result of the operation.
Hydrocephalic idiocy is caused by atrophy of the brain sub-
stance from pressure by an excessive accumulation of fluid
within the lateral ventricles, the foramen of Magendie being
closed. The circumference of the head is enormously increased.
In the congenital form the ventricles are elongated; in the ac-
quired form they are increased in their vertical and transverse
diameters. At least some of these cases are due to congenital
syphilis. A few cases of hydrocephaly exist in which there is
apparently no impairment of intellect.
In hydrocephaly the greatest increase takes place at the temples
and the distance between the eyes is increased. The head is
globose. This feature serves to distinguish it from the rarer
condition of inflammatory hypertrophy of the brain, in which the
greatest increase is above the superciliary ridges.
Eclampsie idiocy is the name applied to those cases in which
the state of weak-mindedness is ascribed to a series of fits occur-
ring during the first year of life, generally during teething. It
seems doubtful whether such cases merit the distinction of a
separate class. The probability is that they are genetous idiots
VARIETIES OF IDIOCY 503
whose first symptom of cerebral weakness is a series of teething
convulsions.
Epileptic idiocy exists as well as epileptic insanity, and it is
desirable to draw between the two a distinction, which is bound
to be based upon the age at which the mental faculties first
show signs of degeneration. Dr. Ireland fixed this age at seven
years.
Epileptic idiots can scarcely be regarded as educable. The
usual course is that they acquire a certain amount of knowledge;
Fic. 79.—HYPERTROPHIC IMBECILE.
Circumference of head =29 inches.
Binauricular diameter ==124 inches.
Antero-posterior diameter = 12} inches.
Width of forehead = 4} inches.
then there comes a series of fits which obliterate that knowledge
and the teacher has to begin all over again, only for the same
process to be repeated time after time.
In the chapter on epilepsy it will have been noticed that we
are at last beginning to understand the disease, but I doubt
whether even Dr. Pierce Clarke’s methods will ever be of much
service to the epileptic imbecile.
504 MIND AND ITS DISORDERS
Epiloia is the name given to a group of cases of mental defect
associated clinically with a chronic affection of the skin (adenoma
sebaceum), epileptic fits and albuminuria. The cutaneous affec-
tion is commonly limited to the face, but it may appear on the ©
chest and other parts of the body. Post-mortem adenomatous
tumours, similar to those in the skin, are found in the cortices.
of the brain and kidneys.
Incomplete cases occur in which adenoma sebaceum is a pure
skin disease without mental defect and there may be cutaneous
lesions with mental defect in which no convulsions occur.
Paralytic idiocy is due to coarse lesions of the brain, usually
hemorrhage or thrombosis occurring at birth or during early
infancy. It is associated as a rule with hemiplegia; but many of
these patients are paralyzed on both sides of the body (diplegia).
Inflammatory idiocy occurs as the result of a chronic en-
cephalitis. According to Ireland it is usually a sequel to one of
the acute specific fevers. In one form of the disease (hyper-
trophic idiocy) the head becomes enlarged owing to an abnormal
increase in size of the whole brain. There is an increase of all
its constituents, not of neuroglia only; but the higher functions
VARIETIES OF IDIOCY 505
suffer on account, it is said, of an increased intracranial pressure
caused by the unyielding bony framework of the skull. If this
be so, the operation of craniectomy might be revived for these
cases.
Sclerotic idiocy is due, as its name suggests, to sclerosis of the
brain. It may be recognized by the occurrence of spasms ~
affecting particular groups of muscles, which sometimes pass
into general convulsions. The sclerosis may be either diffuse or
tuberose and it may lead either to atrophy or hypertrophy of
the cerebrum. The frontal and occipital lobes are usually
affected more than other parts of the brain.
True Syphilitie idiocy is rare, despite the fact that some in-
vestigators have reported that the Wassermann reaction is posi-
tive in rather a large proportion of the mentally deficient. The
diagnosis depends on the usual signs of congenital syphilis, such
as a flat bridge to the nose, scarring at the angles of the mouth
and, later, notched permanent central incisors and interstitial
keratitis.
Idiocy by deprivation of the senses has already been referred to.
Binet and Simon approached the problem of classification from
an entirely different standpoint, and conceived the notion of
comparing mental defectives with normal children of different
ages and assigning them to different “‘ mentalities’. Thus an
imbecile of any age, possessing only the intelligence of a child of
five, is said to be of “‘ mentality 5 ’’, and a defective, whatever his
age, of the intelligence of a child of nine is assigned to “‘ mentality
g’’. Those whose mentality is less than 3 are called “ idiots ”’;
those with mentalities 3 to 7 are called “‘ imbeciles ’’; those with
mentalities 8 to 12 are called ‘“‘ morons ’”’; while adults of mentali-
ties 12 to 15 are regarded as “‘ backward ”’ or “‘ weak-minded ”’.
Otherwise, an idiot is defined as a person who never learns,
through defect of intelligence alone, to communicate with his kind
by speech; an imbecile is one who, owing to defect of intelligence
alone, fails to learn how to communicate with his kind by writing
or reading; and a moron is a person who can communicate with
his kind by speech or writing, but, owing to defective intelligence,
shows a retardation of two or three years in his school studies.
Of course, these terms are inapplicable when a child’s mentality
is the same as his age. Moreover, some margin must be allowed
for social status, education etc.
To ascertain a person’s mentality Binet and Simon have devised
certain tests which can only briefly be given here. For details
the reader is referred to ‘““ A Method of Measuring the Develop-
506 MIND AND ITS DISORDERS
ment of Intelligence of Young Children ”’ (Chicago Medical Book
Co., Chicago) and “‘ Mentally Defective Children” (Edward
Arnold, London). Both are translations of works by Binet and
Simon.
The series of tests used in the method, grouped according to
age, is as follows:
Three Years.
Shows nose, eyes and mouth.
Repeats two digits :—7-5.
Enumerates objects in a picture.
Gives family name.
Repeats a sentence of six syllables.
Four Years.
Gives own sex.
Names key, knife and penny.
Repeats three digits :—4-9-6.
Compares two lines (Fig. 81—first pair).
Five Years.
Compares two weights.
Copies a drawing of square... 7 2... . 2-1-0 eee
Repeats a sentence of ten syllables.
Counts four pennies.
Six Years. He
Distinguishes between morning and afternoon.
Defines in terms of use. (
Copies a'lozenge-shaped figure, /.. 7.5 ee \ j
Counts thirteen pennies. .
Compares faces from the esthetic point of view
(Fig. 82; three pairs). "
Seven Years.
Can point to right hand; left ear.
Describes a picture.
Executes three commissions (e.g., “‘ Put this key on that chair;
Close the door; and Bring me that box ’’).
Gives values of nine sous, three of which are double (half-
pennies and pennies).
Names four colours (red, yellow, blue and green).
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508 MIND AND ITS DISORDERS
Eight Years.
Compares two remembered objects—e.g., a fly and a butter-
fly. (Two differences should be given.)
Counts backwards from 20 to o.
Indicates omissions in pictures (Fig. 83).
Gives day and date.
Repeats five digits (e.g., 5-7-3-2-4).
a he ae Ve q As
oy PSR
ee > om = 71 )
ai Ve. 7, 3 yf
& eed, " abs
Deve! )
aa
fy 1S
ne ) —
ay ) Y [ .
Fic. 82.—v. MENTALITY 6.
Irom Dr. Drummond’s translation of ‘‘ Mentally Defective Children”’,
by Binet and Simon. (Arnold, London.)
BINET-SIMON TESTS 509
Nine Years.
Gives change from a shilling in mixed coins in the guise of a
game.
Defines in terms superior to use.
Recognizes all the pieces of our money.
Enumerates the months.
Gives rational answers to easy questions (e.g., ““ What would
you do tf you broke something belonging to somebody
cise? ').
Fic. 83.—v. MENTALITY 8.
From Dr. Drummond’s translation of ‘‘ Mentally Defective Children”’,
by Binet and Simon. (Arnold, London.)
510 MIND AND ITS DISORDERS
Ten Years.
Arranges five weights in order.
Copies drawings from memory.
Criticizes absurd statements (e.g., ““Why 1s there always
a yellow dog when two men quarrel in the street ?’’).
Gives rational answers to difficult questions (e.g., “ Why.
should you judge a person by Mus acts rather than his
words ?’’).
Uses three given words in two sentences.
Twelve Years.
Resists suggestion (length of lines) —Fig. 81.
Composes one sentence containing three given words.
Says more than sixty words in three minutes.
Defines abstract terms, such as charity, justice, kindness.
Discovers the sense of a sentence the words of which
are mixed (e.g., “‘ For-an-the-at-hour-early-we-country -
started ’’).
Fifteen Years.
Repeats seven digits.
Gives three rhymes with the same word (e.g., meet).
Repeats a sentence of twenty-six syllables.
Interprets a picture.
Solves a problem from several facts, e.g. :
“My neighbour has just received some singular visitors.
He received one after the other: a doctor, a lawyer and a priest.
What is going on at my neighbour’s ?”’
ADULT.
A sheet of paper is folded in four, and a small triangle is cut
from the folded edge. The examinee draws the paper as he
supposes it would appear if unfolded (Fig. 84).
A visiting-card is cut diagonally (Fig. 85).
The examinee is required to draw the figure which would
appear if the lower triangle were turned over with A C applied
tO seb and Gro:
Gives differences of meaning of abstract terms—e.g., laziness
and idleness. Gives three differences between a president of a
republic and a king.
BINET-SIMON TESTS 511
_ Gives the meaning of a simple philosophical paragraph which
has been read to him.
Binet and Simon realize that their tests elicit only one impor-
tant feature of mental deficiency. Otherwise the mentally defec-
tive does not resemble in many ways a normal child. However
skilful his teacher may be, the imbecile will never progress at the
Fic. 84.
BiGe OS:
same rate as a normal child younger than himself, and he will
never reach adult mentality. Further, the imbecile has lived
longer than the normal child, and has therefore acquired more
knowledge in certain directions; for example, his vocabulary is
larger and he may even have achieved some acquaintance with
a foreign tongue, usually French. In short, his knowledge is ill-
balanced.
512 MIND AND ITS DISORDERS ~
Again, the mentally deficient exhibit such traits as defects
of speech and peculiarities of reasoning, comprehension and
imagination, which do not occur ina normal child. After passing
their mentality test, for example, they are lable to turn away
and talk a lot of nonsense, quite unlike a normal child of the
same mentality. Also we have to consider certain vicious ten-
dencies, garrulity, unruliness and lack of attention, which are |
not observed in the normal child.
Criticisms that have been offered of the Binet-Simon tests are
that the mentalities given for some of them are not applicable
to English and American children, also that there is meagreness
of tests for the higher and lower mentalities. Accordingly they
have been revised and amplified, especially by Stanford and
Termanin America. There are many other systems of intelligence
testing; but they all result in recording the intelligence quotient
or I O ofa patient, that is age In Yeats A child is to be regarded
mental age
as mentally deficient if the I O is lower than 0°75.
Morbid Anatomy.—The lesions found in the brains of idiots
are too numerous for detailed description in a work of this nature.
. In addition to microcephaly, hydrocephaly, cerebral hyper-
trophy and sclerosis mentioned above we meet with malforma-
tions of the brain, such as abnormal arrangement of the convolu-
tions, microgyria, pseudo-porencephaly (cysts marking the site
of old hemorrhages), local atrophies and atrophy of the cerebral
hemisphere of one side with or without atrophy of the cerebellar
hemisphere of the opposite side. In some rare cases there is
complete absence of one or more convolutions, the arachnoid
bridging over the gap while the pia mater lines a funnel-shaped
opening into the lateral ventricle and becomes continuous with
the ependyma (true porencephaly). In some rarer cases the
corpus callosum is absent.
Prognosis.—Idiots and imbeciles can never attain the mental
capacity of normal individuals; but by suitable training many
are capable of considerable improvement, sufficient in some
cases to enable the patient to earn his own living. It is difficult
to frame rules applicable to every case whereby it may be deter-
mined whether a child is educable or not. Each case has to be
considered on its own merits. The following principles, however,
may be considered fairly safe guides :—
Extreme forms of idiocy in which there is complete absence
of perception and instinctive attention are absolutely incurable
(mentalities I and 2). Little hope of improvement need be
TREATMENT OF AMENTIA 513
entertained of patients who suffer from convulsions from time
to time or of idiots with a history of convulsions during the
first two years of life. Little improvement can be expected in
‘wet and dirty ”’ cases. Extreme emotional reaction generally
means that the child cannot be taught much. The prognosis
is bad if he is unable to walk. Lastly if he does not experience
the sense of hunger and the desire for food, if at meal-time he
does not care whether he receives food or not when he sees it
passed round to others at the table, there is not much probability
of his ever being educated.
Puberty is apt to be a trying time for the imbecile; he is liable
then to undergo a certain amount of temporary retrogression
or to develop dementia przecox.
Idiots seldom live long owing to their low power of resistance
to disease. It is said that they are peculiarly liable to phthisis;
but this opinion is not held by those in charge of idiot estab-
lishments where the sanitary arrangements are unfavourable for
infection.
Treatment.—It is essential that idiots and imbeciles should
live under very hygienic conditions. They should be warmly
clad and their clothes should be cut in such a way as to conceal
their deformities. When possible the habit of cleanliness should
be enforced and control of the instincts be taught by means of
firm but kindly discipline.
The senses require to be cultivated by appropriate means into
the nature of which we cannot enter here. Co-ordination of
movement may be developed by various devices, such as getting
the child to stand on a ladder and hold on to one of the rungs,
by simple games and gymnastic drill which may be set to music.
After some years it is often possible to teach a simple trade.
In the education of these patients it is not to be expected that
they will attain any degree of learning. If they can be taught
to make themselves useful at a trade such as shoe-making,
tailoring, gardening or, for women, laundry, sewing or house-
work, that is all that is required to make them happy and more
or less self-supporting. For them reading and writing are
“extras ’’ as much as Latin and Greek to the ordinary school-
boy; but many acquire these extras and can even do a little
arithmetic.
It ought to be added that education of the mentally deficient
should be assigned to teachers specially qualified for the task.
It must not be supposed, for example, that the ordinary methods
of education of a child of six are applicable to an imbecile of
33
514 MIND AND ITS DISORDERS
mentality 6. The two children* are comparable only in the
sense suggested by Binet and Simon. Left to itself, the child
of six would educate itself, as has been demonstrated by Dr.
Montessori; but, paradoxical as it may seem, although her method
of education is based on that used in establishments for the
mentally deficient, they are not strictly applicable to these cases.
The mentally defective require an education specially adapted to
mental deficiency. }
* In establishments for the mentally deficient the inmates are always
called “‘ children’’, whatever their actual age may be.
CHAPTER 2OX1V.
COMBINED INSANITIES.
IN an earlier part of this manual it was pointed out that the many
functions of the mind are interdependent and that our study of
them as separate forms of mentation is merely for convenience.
Much more should any particular classification of mental disorder
be regarded as merely convenient in the light of existing know-
ledge. It should therefore not surprise us to meet occasionally
with cases which can only be explained by referring them to two
or more of the insanities described in this volume; for, on the one
hand, identically the same etiological factors may be responsible
for symptoms of different mental disorders in the same patient
and, on the other, he may have been exposed to the various
causative agents of several mental disorders.
To take an extreme example: a man aged fifty-three, previously
to the onset of his illness, suffered from occasional epileptic fits.
While in West Africa he became infected with dysentery and had
an exhausting diarrhcea for three months. The dysentery was
cured at the Dreadnought Hospital, Greenwich, whence he was
transferred to Bethlem. On admission he was found to have
extensive anesthesia and hallucinations of vision and hearing.
There was also a history of a severe blow on the forehead during
a tram accident shortly before his illness. The degree of his
disorientation of time and place may be gathered from the fact
that he thought that the year was 1815, and that he was in
Melbourne, Toronto or Pernambuco. His perception was so
deficient that, although he was lying in bed, he believed that he
was in either a theatre or a church. He did not know his own
name, could not recognize his wife and his memory was a blank.
Here we have to do with an insanity in which are present the
combined results of epilepsy, intoxication, exhaustion and head
injury.
The study of these combined psychoses is yet in its infancy
and it is impossible at the present time to give a detailed account
of them; but it is hoped that the following remarks will help
235
516 MIND AND ITS DISORDERS
the student to understand these difficult cases and to avoid error
in diagnosis.
Maniacal-Depressive Cases.—With these the most common
complications are exhaustion symptoms; so much so that in the
description of the intermittent and periodic psychoses reference —
to such symptoms was found to be unavoidable.
It will be remembered that the cardinal symptoms of intoxica-
tion of the nervous system by the products of exhaustion and
by many other poisons are analgesia, hallucinations, imper-
ception, disorientation in time and place and loss of memory.
Now when a patient suffering from mania or melancholia also
presents any of the above symptoms the case cannot be regarded
as uncomplicated. Cases of maniacal-depressive insanity with
analgesia, hallucinations or both should be described as mania
(or melancholia) with exhaustion symptoms. Analgesia and
hallucinations do not occur in an uncomplicated maniacal-
depressive psychosis, anergic and post-maniacal stupor being
excepted.
When exhaustion (confusional) symptoms complicate an attack
of mania or melancholia the illness must be expected to last much
longer than it otherwise would. Hallucinations, especially cf
hearing, are of grave significance in melancholia, but are of minor
import in mania. Analgesia is not so serious a symptom as
hallucination, provided it is not prolonged for more than a
month after the patient comes under treatment. Catatoniac
symptoms are occasionally met with as a complication of
maniacal-depressive insanity.
Maniacal-depressive insanity appearing for the first time late
in life is hable to be complicated by early symptoms of chronic
cortical atrophy. There may be a slight degree of imperception,
loss of memory for proper names and for quite recent events, and
a tendency to eroticism. Insight js apt to be deficient. The
presence of arteriosclerosis does not materially affect the prog-
nosis of mania, but melancholia is not likely to be cured when
the cerebral arteries are diseased.
Exhaustion Cases and Dementia Precox.—Acute confusional
insanity is sometimes complicated by cataleptic and catatonic
phenomena to such an extent as apparently to justify the diag-
nosis of dementia preecox., .On the other hand, dementia preecox
may be complicated by exhaustion symptoms. If the patient
is completely disorientated I generally regard the case as being
primarily one of acute confusional insanity, the catatonic and
cataleptic phenomena being secondary. Under such circum-
COMBINED INSANITIES 517
stances the prognosis is good, provided that the treatment is
apt and persistent. The illness usually lasts about a year. If,
on the other hand, disorientation is slight and especially if the
patient shows a tendency to keep one hand constantly over the
external genitalia I regard the case as being primarily one of
dementia precox, the prognosis being hopeless. These, of course,
are mere working rules; they are not infallible.
Alecoholie Cases.—The student must be prepared to meet with
cases which at first present the symptoms of an acute form of
alcoholic psychosis and subsequently turn out to be examples
of a chronic psychotic form, when the effects of acute intoxica-
tion have passed away. Similarly he must be prepared to meet
with cases which present symptoms of alcoholic insanity on
admission and subsequently turn out to be cases of intermittent
insanity, dementia precox, general paralysis, arteriopathic
dementia; neurasthenia, epilepsy or some other mental disorder;
the symptoms having, during the first few days, been masked
by alcohol.
Neurasthenies frequently have paranoid symptoms or morbid
fears and vice versa, obsessional cases sometimes have some
neurasthenic symptoms.
Lastly it must not be forgotten that attacks of mania, melan-
cholia, anergic stupor, collapse delirium and acute confusional
insanity may and do occur from time to time among imbeciles,
paranoiacs, epileptics, neurasthenics and others. In all such
cases we must expect the one disorder to be modified by the
other. It is only necessary for the student to recognize the
possibility of these combinations in order to be prepared for
them when they occur.
CHAP FERS V=
FEIGNED INSANITY.
INSANITY is sometimes feigned by criminals with the object
of escaping punishment, by soldiers and sailors in the hope of
obtaining discharge from the services, by others seeking to
evade duty or legal obligation imposed on them by a contract
into which they have entered, by hysterical patients seeking
sympathy and, in rare instances, by enterprising newspaper
reporters who, in search of copy, endeavour by this means to
gain admission to an asylum.
During the War mental experts had a large experience of
cases of malingering in men seeking a medical certificate to
support an application for exemption from military service,
mostly men of a certain class of a certain race. Imbecility was
generally their choice.
In such cases a medical man may be called to determine whether
the mental disorder is real or assumed. When, under these
circumstances, he is confronted with a subject suspected of
malingering he should frankly make the object of his visit known
and, if there is any detective work to be done, this should be
relegated to an observant and intelligent attendant.
A careful history of the mental symptoms must be taken. It
should be noted whether there is any motive for malingering
and, if so, what was the temporal relationship of the mental
symptoms to the motive. It is also to be ascertained whether
there were any premonitory symptoms of mental disorder,
whether it developed suddenly and whether there were any
previous signs of ill-health. Due attention should be paid to
any history of previous mental disease in the subject or his
family.
Several visits are usually necessary before coming to a decision.
The patient should be examined for the usual physical concomi-
tants of mental disease, such as physical stigmata, furred tongue
and disordered digestion with consequent refusal of food, and
constipation.
In uncomplicated cases the diagnosis is easy, the chief charac-
teristics of feigned insanity being (1) incongruity of symptoms,
518
FEIGNED INSANITY 519
(2) exaggeration of symptoms (they are overdone) and (3) ten-
dency of the subject to show any symptom which appears to be
expected of him. One mode of eliciting the last tendency is to
remark in the patient’s hearing that there would be no doubt
as to his insanity if such and such a symptom were present.
The ruse is not often successful; but, in some cases, the said
symptom makes its appearance at the next visit.
The diagnosis is not always a simple matter; for insanity is
sometimes simulated by those who have previously had an attack
of mental disorder or, at the time of examination, exhibit symp-
toms of undoubted mental instability. Indeed, we have to be
prepared for subjects who are really suffering from one form of
insanity but simulate another.
As the reader has learned from previous chapters, insomnia
is a common feature of the acute forms of mental disorder; but
a malingerer sleeps soundly for many hours at a time, especially
if he has set himself the task of simulating acute mania or some
other form of motor excitement.
The simulation of anzsthesia is readily detected and usually
arrested by faradism with a wire brush.
If a malingerer feigns imperception when he is asked to recog-
nize common objects, he makes more stupid mistakes than those
of a patient who is really suffering from imperception. He may,
for example, call a coin a watch and a pencil a key. Hallucina-
tions are seldom feigned unless they are suggested to the subject.
Amnesia is a symptom which easily lends itself to simulation
and is therefore often feigned. The malingerer, however, usually
makes the mistake of introducing this symptom among others
with which it is incompatible. He will, for example, feign acute
mania with loss of memory for remote instead of recent events.
He will remember trivial factors of an incident, such as a crime
which he has committed, but will pretend loss of memory of the
most important factor, viz., the crime itself.
When delusions are feigned the malingerer gives expression to
them obtrusively; a patient who is really deluded keeps them
in the background. Again, feigned delusions change from day
to day, being sometimes expansive, sometimes depressive. It
may usually be observed, too, that the delusions are at variance
with the subject’s conduct. Delusions of persecution are fre-
quently selected; most of my war cases added them to their
feigned imbecility.
Motor excitement corresponding to the popular conception of
“raving madness ” is sometimes feigned; but nobody can main-
520 MIND AND ITS DISORDERS
tain such excitement hour after hour and day after day like a
person who is really insane; the work is too hard. Similarly
the malingerer sets himself a difficult task if he attempts to be
incoherent in speech; the deception can only be kept up for a
minute or so. :
The conduct of a malingerer is most faulty and ridiculous
when he is under ostensible observation; it is normal when he
thinks he is unobserved. An insane patient, on the contrary,
tends to pull himself together when he is being observed.
Simulation of melancholia is infrequent. Indeed, the malin-
gerer rarely attempts to feign any particular insanity; he merely
wishes to be thought “ mad”’ and takes no account of the fact
that the modern study of mental disease has reached such pre-
cision as to render detection fairly easy.
CHAPTER OAAVE:
SOME DISEASES TO WHICH THE INSANE ARE
ESPECIALLY LIABLE,
PHTHISIS.
THE death-rate from phthisis in our large county asylums, as
compared with that in the general community, is so alarming
that some years ago the Medico-Psychological Association
appointed a special committee ‘“‘ to make some practical sugges-
tions for the isolation of phthisical patients in asylums’’. This
action of the Association was the direct outcome of a prize essay
by Dr. F. G. Crookshank, ‘“‘ On Phthisis Pulmonalis in Asylums ”’
and a paper by Dr. Eric France on “ The Necessity of Isolating
the Phthisical Insane ’’.
Dr. Crookshank pointed out in his essay that, although not
more than 7-5 per cent. of the insane are phthisical on admission,
the official death-rate from phthisis among the insane, which is
probably too low by one-third or one-half, is 14:6 per 1,000 of
the average resident population in English asylums; whereas
the phthisis death-rate among the general population of England
and Wales is 1-46 per 1,000 living. In other words, death from
phthisis is ten times as frequent in asylums as it is among the
general population.
The causes of the frequency of phthisis in asylums are not
far to seek; for it is found, on examination, that in most of our
large county asylums every etiological factor is at work.
In the first place it has been pointed out by Dr. C. J. Shaw,
Medical Superintendent of Montrose Asylum, that the insane
are, as a Class, more liable to tubercular infection than the sane,
their capacity of resistance to tubercle, as estimated by the
opsonic index, being deficient (0:8 to 0-9). The opsonic power
is especially deficient during the acute stages of mental disorder
and in cases of dementia praecox and general paralysis.
Further, the respiration of depressed and demented patients,
who form the majority of an asylum population, is shallow and
infrequent. Not only is the characteristic favourable to the
521
522 MIND AND ITS DISORDERS
development of phthisis; it renders early diagnosis difficult.
With such patients the physical signs of phthisis may be so
trifling as to lead the medical officer to the conclusion that he is
dealing with an early case, whereas it is found at the autopsy
a few weeks later that the lungs are riddled with cavities.
Certainly it is impossible to diagnose phthisis in such patients
as early as in a sane individual. | |
Other potent factors in the causation of phthisis in county
asylums are underfeeding and overcrowding, enforced upon
medical superintendents by lay committees with excessively
economical tendencies, and countenanced even by the Board of
Control.
“Under the most favourable circumstances, the floor-space
allowed by the Commissioners corresponds to only 1,800 cubic
feet of air per hour for ordinary patients (instead of 3,000),*
and for sick patients to only 2,376 instead of the needed 3,000
to 4,000.* On their own estimate, overcrowding existed, on
January 1, 1898, in thirty-six out of the seventy-seven county
and borough asylums. In these thirty-six asylums there was, on
the estimated dormitory and single-room accommodation, over-
crowding to the extent of 1,486 persons.” “It is childish to
assert that half a crown or less per week is enough to spend on
food.” “ Surely it would be difficult to find institutions which
afford such opportunities for the dissemination of phthisis germs
as do our asylums. Consider a community existing under condi-
tions that preclude, for many, adequate exercise in the open air;
spending long hours in overcrowded day-rooms and dormitories ;
a community of filthy and careless habits, and already phthisical
in the proportion of 15 to 25 per cent. Such a community is
formed by the inmates of every county asylum ”’ (Crookshank).
The Tuberculosis Committee pointed out that the occupation
of hair-picking in the upholsterer’s shop is a dangerous one,
having regard to phthisis. Not only are sharp-pointed particles
of hair-dust liable to be inhaled and to wound the lung, but the
hair is itself liable to be impregnated with tubercle bacilli.
The Committee found that the death-rate from phthisis was
higher in asylums built on bad and damp soil than in those built
on good and dry soil. They also remark on the unsatisfactory
heating and ventilation of many asylums.
The remedies are obvious. In the first place more cubic space
must be allowed for patients. It is held that this should not
be attained by building larger establishments, but by more
* Parkes’s standard.
PHTHISIS IN ASYLUMS 523
strictly limiting the number of patients in asylums not larger
than those already in existence. It is further held that not more
than fifty patients should sleep in the same dormitory, however
large. With competent nurses, properly trained, the air in a
dormitory can easily be changed as often as four times in an hour
without undue draught. During the day every aperture by
which air can gain access to the dormitory should of course be
opened to its fullest extent. Similarly an intelligent attendant
can change the air in the day-rooms five or six times an hour
without undue draught and surely it is possible, by a little
thoughtful organization, to arrange that every patient not under-
going bed-treatment should have a minimum of four hours daily
in the open air, weather permitting.
Patients should be restrained as much as possible from the
dirty habit of spitting on the floor of the ward or on the ground
of the airing-court. The Tuberculosis Committee suggested
that a wide-mouthed cup with contracted neck and containing
some disinfectant might be fastened to the wall by a padlocked
band. Any sputum found on the floor should be immediately
wiped up with a rag, and this immediately burned. Hair, coir
and flock should always be disinfected before they are sent to
the upholsterer’s shop.
The diet ought to be more generous than at present. In view
of the importance of a liberal diet, not only for the prevention of
phthisis, but also for the cure of insanity, it should be impossible
for any patient to complain justly that he cannot get enough food.
It is imperative that phthisis be recognized as early as possible.
Whenever a patient suffers from cough or is seen to be in ill-
health, his temperature must be taken regularly every night for
a few weeks, his weight taken every week in order to discover
whether he is losing flesh and his chest carefully examined from
time to time. Wasting of the upper part of one trapezius
muscle is an early sign; in looking for this the doctor should
stand behind the patient. One mode of investigation is to
obtain a small pipetteful of blood and to estimate the opsonic
index. V. Pirquet’s reaction with pure tuberculin is a rather
more reliable test. As a rule, tubercle bacilli cannot be dis-
covered in the sputum from early cases.
Lastly, phthisical patients are to be isolated from the non-
infected and to receive treatment. At present no sanatorium
exists for the phthisical insane; but some establishments have
now instituted an arrangement whereby their phthisical patients
can live entirely in the open air. Beds can be placed under a
524 MIND AND ITS DISORDERS
shelter against a wall facing south, somewhat like a cloister.
The patients can remain in bed the greater part of the day and
receive an allowance of 3 or 4 pints of fresh milk in addition to
their ordinary food.
For further details of the diagnosis and treatment of phthisis —
the reader is referred to textbooks on general medicine.
ASYLUM DYSENTERY. ©
This disease, which was long known under the name of “ ulcera-
tive colitis’’, is now considered to be the bacillary dysentery
familiar to dwellers in the tropics and is ascribed to infection
by a modified Bacillus dysentert.e of Shiga.
Outside the asylum population dysentery is a rare disease
in this country. Unfortunately it is deplorably common in
asylums. In 1911, 1,203 of 99,742 inmates of county and borough
asylums were reported to the Commissioners as suffering from
dysentery. Of these, g12 recovered and 240 died, 51 remaining
under treatment at the close of the year; and this in spite of
the fact that sixteen of the ninety-five asylums were reported
free from dysentery. There is not the slightest doubt that
the true condition of affairs is very much understated by these
figures. On the one hand, Dr. Mott tells us that the disease
sometimes exists without giving rise to characteristic symptoms
and is not discovered until the case reaches the post-mortem
table; on the other hand, many superintendents are unwilling
to report dysentery as a cause of death and thus to proclaim their
particular asylum to be insanitary when other possible causes of
death can be discovered.
Etiology.—As already stated, the disease is infectious. Evidence
goes to show that it is communicated to the healthy by means
of the evacuations from the sick, as in typhoid. When once
dysentery is introduced into an asylum, even of the most modern
and hygienic type, it is extremely difficult to drive it out again.
The same remark applies to individual wards and even indi-
vidual beds of an institution. Still more is it applicable to
individual patients for, according to Dr. Mott’s report, active
lesions may be found post mortem in the colon of a patient
who has been free from all symptoms of the disease for years.
Hence it is liable to be spread through the injudicious transfer
of cases from one ward to another or, worse, from one asylum
to another. In so far as transfers are frequently necessitated
by the overcrowded state of our asylums, overcrowding is to
be regarded as a contributory cause of the disease.
Assy LUM DYSENTERY 525
Perhaps the most important causes of its relative frequency
in asylums are the filthy habits of many of the patients them-
selves, in regard to which it is unfortunate that asylum nurses do
not, as a rule, receive sufficient instruction concerning the nature
of infection and the mode of disinfection of contaminated articles.
As is well known, the disease is not limited to the insane, even
in asylums. Experience has proved that medical officers and
nurses are just as lable to infection.
Incidentally it may be mentioned that dysenteric lesions are
found post mortem twice as frequently in females as in males
and that alcoholics appear to be more liable to the disease than
other patients.
Symptomatology.—Asylum dysentery usually sets in with rise
of temperature (101° to 103° F.) and a rigor. Within the next
two days there are colicky pains followed by persistent diarrhoea
which may be accompanied by tenesmus.
On examination the abdomen is found to be moderately dis-
tended and tender, especially in the hypogastrium. The tongue
may be either unduly red and dry or coated with a white or
brown fur. The pulse is small and frequent.
The evacuations are loose; their odour is offensive and so
characteristic that the medical officers of institutions where the
disease is rife can recognize a case from the odour alone. The
stools contain blood and slime to a variable extent, the slime
consisting almost exclusively, according to Sir Frederick Mott,
of polymorphonuclear leucocytes and mucin, with a few decay-
ing columnar cells.
Sir Frederick recognizes seven different clinical types of asylum
dysentery :
“yy, The acute case, with preliminary fever, lasting till death
supervenes in about two to ten days.
“2. The acute case, with preliminary fever, and a temperature
which falls rapidly as the collapse proceeds.
‘3. The case with mild fever, 101° to 103° F., and diarrhcea for
a day or two, accompanied by diarrhoea with blood and slime
in the stools for a few days to a week or more; terminating,
however, in recovery.
“4. The mild case without fever, but with diarrhoea, accom-
panied with blood and slime, lasting over two days. In some of
these cases there may have been initial fever, which was overlooked.
‘5. Cases of varying degrees of severity in which, after an
interval of a few days, symptoms recur, sometimes with fatal
results and sometimes with recovery.
526 MIND AND ITS DISORDERS
“6. Cases which do not clear up after the first week or two,
but which become chronic: the patients continuing at more or
less intermittent intervals to pass bloody, slimy, diarrhceal
evacuations for months. Such are common.”
“7. Cases of intermittent or prolonged diarrhoea, in which
neither blood nor slime has been noticed in the stools, and yet
post-mortem dysenteric lesions of a similar nature have been —
found.” 7
Sir Frederick Mott further draws attention to the fact that
asylum dysentery may coexist with phthisis and may then be
mistaken for the diarrhoea of the latter disease.
Morbid Anatomy.—The mucous and submucous coats of the
large intestine are red and swollen and the mucous coat is firmly
adherent to the underlying tissues, so that it cannot be moved
on them. The whole colon may be the seat of all shapes and
varieties of ulcer, varying in size from the most minute up to
several inches in length and breadth. Primarily they are cir-
cular, but by coalescing they may acquire a serpiginous outline.
Hemorrhagic points, black or grey sloughs and healing edges
may be seen here and there, according to the acuteness and
intensity of the disease.
Treatment.—In the interest of the non-infected it is of prime
importance that all cases of dysentcry be isolated in a separate
building from other patients. Clothing, bedding and _ utensils
should be disinfected as carefully as if the patients were suffering
from scarlet fever or diphtheria. The nurses must be made to
understand that they are dealing with cases of an infectious
disease and they should be instructed in the general principles
and methods of preventing the spread of such diseases. Special
care is to be taken to disinfect at least the nozzles of enema
syringes used for these cases.
The treatment of patients suffering from the disease consists
of disinfection of the large intestine and prevention of collapse.
The former may be effected by the administration of salol,
6-naphthol or salicylate of bismuth by the mouth and by lavage
of the large intestine by copious enemata of lukewarm water
to which a small quantity of some non-irritating antiseptic, such
as creasote or lysol, may be added. If the diarrhoea be not
excessive, magnesium sulphate may be regularly given by the
mouth to assist in the elimination of toxic products.
For the mitigation of an exhausting diarrhcea, brandy, almost
neat, should be given in 1-ounce doses by the mouth and starch-
and-opium enemata administered per rectum,
CUTANEOUS AFFECTIONS 527
The patient is of course to be kept at rest in bed and to use
the bed-pan. To be orthodox the diet should be liquid and
highly nutritious but non-irritating and of small bulk. These
qualities are to be found in milk, given with barley-water, and
good meat-essences, the latter being neither hot nor cold, but
warmed to a temperature of about go° F. But I know of a
medical man who cured himself of dysentery of four years’
standing by taking porridge every morning and returning to an
ordinary diet.
A serum has been prepared by immunizing horses for the
bacillus of Shiga and this has had much success in treatment
of the disease. It should be given in doses of 20 c.c. two or
three times a day. I believe it can be obtained from the Lister
Institute.
CUTANEOUS AFFECTIONS.
It is a matter of common observation that the skin of most
patients suffering from mental disease is unhealthy and sallow.
In many cases it emits an unpleasant characteristic odour which
I believe to be of bad prognostic significance; and there are
certain cutaneous disorders which occur more fréquently among
the insane than among the sane. This association between
cutaneous and nervous diseases might very well be expected in
view of the common origin of the cutaneous and nervous systems
from the epiblastic layer of the embryo and in view of our
experience that those drugs which have medicinal or toxic
influence on the skin are to a large extent identical with those
which have a similar influence on the nervous system.
The insane are, of course, liable to the same skin affections as
other people. There are also certain of these affections to which
they are especially subject. These are seborrhcea and acne,
erythrasma, hypertrichosis, anomalies of pigmentation, so-called
“insane fingers ’’ and adenoma sebaceum.
Seborrheea is common enough among the sane, but it is rela-
tively more frequent and more severe among the insane. Most
commonly it affects the scalp, where it causes dandruff and
thinning of the hair. The disease sometimes goes farther than
this and gives rise to inflammation of the scalp (seborrhceic
dermatitis or eczema capitis). There is no danger in the disease,
except to the patient’s personal appearance, but it is desirable
that the senior members of the nursing staff should be instructed
as to its nature; otherwise they may blame their juniors for the
528 MIND AND ITS DISORDERS
dirty condition of a patient’s head, whereas no amount of brush-
ing per se will get rid of dandruff.
Next to the scalp the most common site for seborrhcea is just
above the ale nasi where little pellets of sebum may often be
seen to have accumulated on insane patients.
Acne Vulgaris, which is really the same disease as séboroam |
affecting the face, chest and back, is extremely common among
insane adolescents. It is too well known to require deserineae
in a book of this nature.
Tveatment.—In the treatment of these conditions it is essential
to begin with the scalp. When the hair is full of dandruff it is
useless to attempt to cure acne. Seborrhcea may be cured as
follows: Wash the head nightly with soap-spirit (soft-soap
2 parts, rectified spirit 1 part) or Packer’s pine-tar soap, wash
all the soap out of the hair with plenty of clean water, then apply
to the scalp (the hair will take care of itself) with a piece of
sponge, a strong solution of perchloride of mercury (I in 250).
This is not too strong for most cases: the scalp will quite com-
monly tolerate a I per cent. solution. If the sebum be collected
in crusts on the scalp or if there be any dermatitis, it is better to
use the following ointment:
Precipitated sulphur fs
é : : of each
Salicylic acid - :
: 10 grains.
Resorcin : rY aoF Bie
Vaseline os Ay is ie I ounce.
This ointment is useful also in treating seborrhcea above the ale
nasi, after the pellets of sebum have been scraped away with
the finger-nail.
Erythrasma.—This is a disease of little importance, apparently
allied to pityriasis versicolor. I have never seen it in the sane,
among whom it is said to be very rare; but I have seen at least
a dozen cases among the insane, among whom it sometimes
occurs in mildly epidemic form in asylums. Erythrasma usually
makes its appearance in the neighbourhood of the genitalia in
the form of reddish-brown spots which spread peripherally and
clear up pari passu in the centre, thus forming reddish-brown
rings. These rings coalesce and give the rash a marginate or
circinate appearance; indeed, the disease has been called by
some authors “‘ eczema marginatum ”’
Treatment.—Erythrasma is due to a fungus, the Mzicrosporon
minutissimum, of feeble vitality. It is therefore easily cured
by a few vigorous applications of a solution of perchloride of
mercury (I in 1,000) or of hyposulphite of soda (x in 8), the
CUTANEOUS AFFECTIONS 529
skin being previously washed with plenty of soap and warm
water.
Hypertrichosis.— Reference has already been made to this
condition in the chapter on the physical stigmata of degeneration.
Many women suffering from mental disorder, especially of the
more chronic varieties, develop bristly hair about the face. In
some cases the growth is sufficiently profuse to attain the dignity
of a beard and moustache. This is a very real affliction to a
sensitive woman and her comfort will be greatly promoted if it
is removed. It is not generally known that this can easily be
done without the use of a razor, by dissolving the hair in a
solution of sulphide of barium or calcium. The best way of
doing this is to make a paste, with water, of equal parts of oxide
of zinc, starch, sulphide of barium and sulphide of calcium.
This is spread over the affected part, left for ten minutes and
then washed off, the dissolved hair coming with it. The paste
should always be freshly made. The slight irritation caused
by it may be relieved by the application of a little powder.
A bristly growth of hair on the face is, of course, characteristic
of masculinity, and its common occurrence in the female insane
has definite relationship with the frequency of repressed homo-
sexuality as a common psychological basis of insanity.
Pigmentary Disturbances.—Vitiligo or leucoderma (piebald
skin) has already been mentioned as one of the stigmata. Other
anomalies of pigmentation sometimes occur, apparently as a
concomitant of mental disorder. On several occasions I have
thought that the complexion of a patient has become much
darker during twelve months’ residence at Bethlem, but it is
difficult to be sure; it is no easy matter to recall the former
colouring of a patient whom one has seen almost daily for twelve
months on end. None of the patients in whom I have suspected
this change of complexion recovered from the mental disorder.
Dr. Hyslop has reminded us of the case, recorded by Laycock, of
“a woman who, during the French Revolution, incurred the anger
of the Parisian mob and with difficulty escaped being hanged in
the streets. Her terror caused a gradual black discoloration of
the whole body, and this remained with her until her death,
thirty-five years afterwards ”’
The name insane fingers has been applied to a low form of
whitlow to which the insane, especially general paralytics, are
liable. The condition appears to be less common than formerly,
probably on account of improved hygienic surroundings and
greater cleanliness on the part of the attendants.
: fs
530 MIND AND ITS DISORDERS
Pellagra.— Until a few years ago it was believed that pellagra
was unknown in this country; but several cases have now been
described, especially in asylums. It is endemic in Northern Italy
and other countries in that region and in the United States of
America, and its incidence used to be ascribed to eating bread
made from diseased maize, but it has more recently been held that
the disease is an infection. It is not communicable from person
to person, but Dr. Sambon has suggested that it is a protozoal
disease caused by the bites of infected insects, especially certain
flies of the genus Simulium. The disease affects the skin, nervous
system and intestinal tract. The skin affection shows itself during
the hot months of the year, when those parts exposed to the
rays of the sun (face, arms and sometimes feet) become first
congested, then pigmented and thickened. Desquamation takes
place during the later months. These processes occur for four or
five successive years; ultimately the skin becomes dry, wrinkled
and atrophied.
At the same time cerebral degeneration takes place in many
of the patients. They suffer from attacks of mental depression
or, less commonly, excitement or stupor. There is also degenera-
tion of the lateral and postero-median columns of the spinal
cord, giving rise to the clinical picture of postero-lateral sclerosis.
Certain associated gastric disturbances have been ascertained by
Agostini to be due to hypopepsia. In fully developed cases the
disease is almost invariably fatal.
Adenoma Sebaceum.—Patients suffering from this disorder
are almost invariably of feeble intellect and the majority are
to be found in institutions for imbeciles. The patients are
usually subject to epileptic fits. We would also gather from a
paper by Dr. Sherlock, now Superintendent of the Darenth
Industrial Colony for Mental Defectives, that the condition is
usually, if not always, associated with patches of tuberose
sclerosis in the cerebral cortex and basal nuclei and with adeno-
matous growths in the kidney which give rise to no clinical
symptoms during life. With remarkable economy of con-
sonants, Dr. Sherlock originally named this disease or symptom-
complex “anoia’’, but he has now rechristened it “ epiloia ”’
These patients all die young; the average age at death in Dr.
Sherlock’s series of twelve cases was thirteen years and ten
months.
Adenoma sebaceum is limited to the face and occurs mostly
on the nose, cheeks and chin. It consists of yellowish-white
waxy-looking papules not larger than a mustard-seed, which are
CUTANEOUS AFFECTIONS sient
covered and surrounded by small telangiectases, giving the face
a mottled appearance.
Lichen Planus has rather a different relationship. That the
disease is sometimes or possibly always of “nervous” origin is
well recognized by dermatologists. A patient suffering from
this malady was introduced to me by a leading dermatologist
and is now being psycho-analyzed. The progress is slow, but
she has gone far enough to convince me that—in her case—
the lichen planus is undoubtedly psychogenetic. For obvious
reasons I can give no details, but the eruption is the fulfilment
of an unconscious wish to have a (syphilitic) rash and she can
now, in some subconscious way, prevent the appearance of a
papule although the prodromal itching has already occurred.
Evans and Jelliffe have reported a case of Psoriasis in which
psycho-analysis disclosed it to be of hysterical origin. We may
therefore infer that at least some other cases may be psycho-
genetic—perhaps all. At any rate, as with lichen planus, we
can say that no pathology of psoriasis has been advanced which
is more satisfactory.
Urticaria is another skin disease whose existence has not yet
been sufficiently explained. It is commonly caused by articles
of diet, such as crabs, lobsters and strawberries, which have
hence acquired the reputation of being indigestible; but they
are not really indigestible. Most people can digest them per-
fectly well and chemically their difference from other foods is
trifling. On the other hand, such articles of diet are just those
which are commonly recognized by psycho-analysts to have an
unconscious symbolic meaning to some patients. It seems
probable, therefore, that urticaria may ultimately have to be
classed as a neurosis.
CHAPTER XXVIL.
CASE-TAKING.
In all cases of illness it is advisable to obtain some history of
the patient before proceeding to examine him, but in cases of
mental disorder this must usually be obtained from the friends
since the statements of patients are liable to be erroneous.
Probably the best way to take the history of an existing illness
is to ask for the first symptom that led the friends to think that
there was anything wrong with the patient and to get a detailed
history of this symptom up to date. Then ask what was the
second symptom noticed and obtain a detailed history of this
up to date, and so on with the third, fourth and subsequent
symptoms. The friends should be asked when the patient left
work, and why. Finally, discrepancies and fallacies should be
pointed out and gaps filled up. It is also well to ask for sup-
posed predisposing and exciting causes with the evidence of
etiological relationship.
An account should then be obtained of the patient’s ordinary
health, of the regularity of the bowels and catamenia, of previous
attacks of similar or allied diseases, of previous illnesses of other
kinds and especially of venereal disease. In the case of women,
evidence of the last is usually to be obtained indirectly by
inquiries respecting skin eruptions, falling of the hair and mis-
carriages.
The patient’s previous habits should be investigated with
respect to food, alcohol, idiosyncrasies and any special liability
to business or domestic worries.
In obtaining the family history the medical man should ask
about the age and general health of the parents, grandparents,
brothers, sisters and children and find out whether there has
been any other mental or nervous disease in the family.
Psycho-analytic experience has taught us to pay rather less
regard to the general family history and to inquire more especi-
ally respecting mental peculiarities of the parents themselves or
their surrogates; for we now know that these have an enormous
influence upon the child during his earlier years, at least as great
as and probably greater than heredity, in laying the foundation
532
EXAMINATION OF PATIENTS 5353
of his subsequent character if he remains healthy, or of his
neurosis or psychosis when he does not.
The examination of patients suffering from mental disorder
cannot be carried out in a routine manner as in the case of those
suffering from other diseases. With the former greater patience
is required and allowances must be made for caprices and whims.
Until fairly recently it used to be the rule for the physician to
direct the course of the conversation to the best of his ability,
the patient being allowed to have his say; but nowadays, if time
permits, we find that we get a far better grasp of the patient’s
mentation by allowing him to do all the talking from the very
beginning. At times, however, this is impracticable. Even then
one cannot, therefore, lay down hard-and-fast rules as to the
order in which the various mental faculties are to be examined.
Further, the doctor will find it necessary to vary his mode of
examination in accordance with the kind of patient with which
he finds himself confronted. It is hoped, however, that the
following may serve as a useful framework on which to base the
scheme of examination. It will be seen that, in the first instance,
this partakes, more or less, of the nature of an ordinary con-
versation.
Greeting:
“Good-morning !”” Offer the hand, and notice whether the
patient’s handshake is of the maniacal, melancholiac or praecox
variety. If he refuses to shake hands, endeavour to find the
reason for his refusal.
Ask his name, age, civil state and occupation. With the object
of making a preliminary test of his memory and of ascertaining
the length of his illness, ask him when he was last engaged at
his usual occupation.
‘How are you?”. (In an institution) ““ Why have you been
brought here ?”’. (In private) ‘“‘ Why have I been called to see
you ?”. The answer to these questions will reveal iter alia
whether the patient has any insight into the nature of his illness
and, ipso facto, whether he has any delusions.
Orientation in space:
‘Where do you live ?”’. ‘‘ Do you know what place this is ?”’.
‘Where is it situated 2”. ‘‘ How far is it from your home ?”.
““ By what route did you come here ?”’.
Orientation in time:
“How long have you been here ?”’. “‘ What is the day of the
week ?”. ‘Of the month 2”. ‘ What month is it ?”’. ‘“ What
year ?’”’. ‘‘Whatcentury?’’. “‘ What time do you think it is ?”’.
534 MIND AND ITS DISORDERS
Associative memory :
“Who brought you here?’”’. “When did you arrive ?”.
“What were you doing a week ago?’’. “A month ago?”.
Here the patient should be asked to give an account of his illness
and to explain or refute the statements in his certificates, if there
are any.
Recognition:
““ Have you ever been here before ?’’. “‘ Do you know who I
am ?’’. ‘“‘ Do you know any of these people present ?”’.
Perception:
“What sort of a place do you think this is? Is it a theatre ?
club ? hospital ? hotel ?”’.
For the purpose of further testing simple perception the
physician should carry a few articles in his pocket, such as a
fountain-pen, a pencil-holder, a matchbox and a button-hook
as well as a few unfamiliar objects to serve as more severe tests
such as a pocket stamp-case, a tape-measure, a tie-clip, a retino-
scope and a pocket electric-lamp. The author usually carries
a small letter-opener with a large lens set in one end of it and
uses it for this purpose. The patient is required to name such
objects and to say what each is for. The same articles may be
used to examine for apraxia by asking the patient to show how
he would use them. Picture-books, especially children’s picture-
books, are also useful. Customarily the author uses two of
these: one, Dean’s rag “‘ Baby’s Object Book ”’, gives pictures and
names of common objects and serves as a mild test for severe
cases; the other, ‘“‘ Proverbs Old Newly Told”’, published by
Raphael Tuck and Sons, has pictures which portray proverbs and
serve as a severe test for mild cases. In practice, the letter-
press is covered up and the patient is required to identify the
object or proverb, as the case may be. It is advisable occasion-
ally to try normal people with these to make sure that the test is
not too severe.
Ideation or the revival of memory images is perhaps best tested
by asking the patient to enumerate a dozen birds, a dozen fishes
or a dozen flowers. In severe cases the physician will do well
to choose objects with which the patient is very familiar; while,
to test the progress of a convalescent patient, he will ask for
something more difficult, e.g., a dozen people whom one sees in
uniform in the street.
Auditory perception is tested by asking the patient to recognize
some familiar sound made behind his back, such as the rattle of
keys, the tearing of paper or the spurt of a soda-water siphon.
EXAMINATION OF PATIENTS 535
Auditory word-perception is tested by giving some simple com-
mand in a monotone and without gesture, e.g., “‘ Put your left
hand on your right shoulder ” (of course, without gesture by the
physician), or, as a slightly more severe test, asking some question
more or less complex, such as “ Would you prefer a brown coin
or a yellow one ?”’.
Taste and smell perceptions may be examined with a series
of test solutions such as, for the former, dilute solutions of salt,
sugar, quinine and citric acid, and for the latter, oil of cloves,
oil of peppermint, tincture of asafcetida and essence of lavender.
Cutaneous anesthesia may be examined and charted at this
stage.
It is while these tests are being carried out that it is best for
the physician to inquire for hallucinations:
“ Are you ever troubled by light or visions of any kind, such
as faces appearing before the eyes, especially at night when your
room is dark ?’’. “‘ Do they occur during sleep or when you are
awake ?’’,
“ Do you suffer from noises in the ears ?”’. “‘ Do you ever hear
sounds which seem like people talking, especially during the
silence of the night when there is nobody present ?’’. ‘‘ Do you
recognize the voices ?’’. ‘‘ What do they say ?”’.
“Do you experience unpleasant or otherwise strange and un-
accountable sensations of taste ?’’. “‘ Or of smell ?”’. “Do you
often think that there is something burning or that the drains are
defective, when other people say that they smell nothing of the
kind ?’’. “‘ Have you any pain or discomfort anywhere ?”’.
Delusions:
“ How do you account for these visions, voices, odours and
other sensations ?”’. ‘“‘ Do you realize that they are the outcome
of your present nervous condition ?”’. ‘‘ Do you think there is
anybody who wishes to do you any harm, who exercises any occult
influence over you or reads your thoughts ?’’. “‘ Do you suffer
from a feeling that something dreadful is going to happen ?”’.
“Are you particularly worried over religious matters ?”’. “* Do
you sometimes feel that you have led a wicked life? And that
your soul is lost ?”’. ‘‘ Are your financial affairs sound ?”’.
Attention, perception and memory may also be tested by
telling the patient a short anecdote and getting him to repeat
it. These can be selected in various degrees of complexity.
Here are two extremes which I commonly employ:
(x) One Jew said to another, ‘‘ Have you taken a bath ?” and
he replied ‘“‘No! Have you lost one ?”’.
536 MIND AND ITS DISORDERS
(2) A Scotchman named Thompson who had been out of work
in Glasgow for a considerable time at last obtained some employ-
ment at the docks. On being asked his name by the foreman, he
replied ‘“‘ Tamson ”’ (as it is pronounced in Glasgow). He set to
work on his job, which turned out to be exceedingly heavy, for
he had to move great barrels of tar as high as himself. So he
returned to the foreman after about a quarter of an hour, and
asked if he had taken his name correctly. The foreman told
him that he had understood his name to be ““ Tamson’’. “‘ Aye,”’
said the man, “‘ that’s a’ richt, I thocht ye micht ha’ pit doon
‘Samson ’ by mistake ’’.
During this examination the doctor will have noticed peculi-
arities about the patient’s general attitude and behaviour. He
will have ascertained whether the prevailing affective tone is
one of depression or exaltation; and he may also test emotional
reaction by showing the patient a comic picture and observing
whether he laughs or not. Further inquiries may now be made
of the nurses or relations concerning his habits.
The medical man may now proceed to ask the patient about
his physical health as in an ordinary medical case, endeavouring
to elucidate symptoms of disorders of the circulatory, respira-
tory, digestive and other systems and, incidentally, he will note
whether he appears to be suffering from hypochondriacal delu-
sions or has distorted views of the nature of his illness.
Then follows the ordinary systematic physical examination.
Note the general aspect and complexion, the colour of the skin
and mucous membranes, the presence or absence of wounds,
bruises, bedsores, scars and skin eruptions.
Observe the facial expression and note physical stigmata and
other obvious deformities.
Examine the general nutrition, note signs of wasting and have
the weight and temperature taken. Observe whether the ex-
tremities are cold, cyanosed or cedematous. Note the frequency
and other characters of the pulse and respiration. Look at the
tongue and see whether it is tremulous, tooth-indented, furred,
coated or plastered, white or brown, dry or moist.
Make an examination of the chest and abdomen and test the
urine.
If the patient suffers from headache, make inquiries as to its
position, characters and associations. Find out during which
part of the night he sleeps and for how many hours.
If he suffers from fits, get a description of them. Is there any
assignable cause for them ? When did they begin ? What were
EXAMINATION OF PATIENTS 557
the longest and shortest intervals between them and when did
those occur? Is there any aura? Ifso, how long after the aura
does the convulsion begin? Is the onset sudden or gradual ?
Does the patient scream at the onset or during the fit ? Does he
bite his own tongue or other people or things ? Does micturition
or defecation take place? Is restraint necessary ? If so, is it
to prevent accident or violence ? What is the duration of a fit ?
Is the termination spontaneous or induced ? What symptoms
occur afterwards—sleep, headache, or automatism ?
If the medical man has an opportunity of observing a fit,
he should note the order of convulsion of various parts of the
body and limbs, the colour of the face, the conjunctival and
pupillary reflexes, the response to a pinprick and the mobility
or immobility of the chest. He should also examine the knee-
jerks during, immediately after and some time after the con-
vulsion.
In the physical examination of the nervous system, special
attention should be devoted to the eyes. The vision should be
tested and errors of refraction recorded. Are the visual fields
contracted? Are there any positive or negative scotomata ?
Examine the fundus oculi with the ophthalmoscope and note
especially whether there is any swelling of the optic disc. Test
the movements of the eyes and note whether there is any nys-
tagmus. Note the size and outline of the pupils, their reaction
to light and the consensual and sympathetic reflexes. Do they
contract on convergence °
Is there any defect of hearing as tested by the tick of a watch ?
Are the muscles or nerves of the limbs tender to pressure ?
Observe the position of the trunk, head and limbs while at rest.
Test whether there is any rigidity of these and whether there
are any abnormal movements, such as tremor. Tremor, other-
wise unobserved, may often be noticed in the fingers by getting
the patient to hold out his hands, dorsum upwards, with the
wrists extended and the fingers widely separated. Examine for
flexibilitas cerea and echopraxia and note signs of negativism.
Test the superficial reflexes, especially the epigastric, cremas-
teric and plantar. Examine the tendon reflexes, especially the
knee-jerk. Test for rectus clonus and ankle clonus. Note dis-
turbances of organic reflexes—deglutition, appetite, vomiting,
defecation and micturition. If there is incontinence, determine
by passing a catheter whether it is reflex or overflow.
Note vasomotor and trophic changes and observe whether
perspiration is excessive or deficient.
538 MIND AND ITS DISORDERS
Observe the gait.
In examining the articulation, get the patient to repeat some
of the usual test phrases: British Constitution, Irish artillery,
Biblical commentators etc.
Is speech excessive or deficient? Is it coherent? Is it
abusive and does the patient use coarse language ? Can he read
correctly ? Can he sing a song with the words ? Note verbigera-
tion, echolalia and pseudolalia. |
Lastly, obtain a specimen of the patient’s writing and study it
carefully; for the whole of a patient’s thought and action are
reflected in his writing.
It is frequently helpful, too, to get him to make some simple
arithmetical calculation on paper, e.g., to multiply 345 by 67.
The scheme given here is intended to serve merely as a basis
for further investigation by methods suggested to the examiner
by the patient’s answers. Those readers who require a more
detailed method of mental investigation will find it in Franz’s
‘Handbook of Mental Examination Methods” (Nervous and
Mental Disease Monograph Series, No. 10).
CHAPTER XXVIII.
GENERAL TREATMENT.
OuR general survey of the nature of mental disease has taught
us that it may be due, on the one hand, to such physical calamities
as gross lesions or toxic influences upon the general nervous
system, local or general metabolic changes etc., or, on the other,
to purely intrapsychic mechanisms. The specific methods for
dealing with the former have already been touched upon in
appropriate places during the earlier chapters of this work.
The latter include the neuroses and biogenetic psychoses. Of
these, the neuroses are almost invariably amenable to some form
of psychotherapy, as also are some of the milder forms of the
psychoses. These may be treated in the consulting-room, in the
mental out-patient departments of general hospitals or at the
patient’s own house; but in quite a large number of psychotic
patients the gross disturbance of the patient’s conduct and other
considerations raise the question whether, nay, imperiously
demand that, the patient ought to be transferred to some forin
of mental hospital for care and treatment.
When this state of affairs arises the first thing to be deter-
mined is the place where he is to be taken care of and treated.
Except in the case of old people to whom the sudden change
from home to institution life is likely to prove irksome and
detrimental, there is not the slightest doubt that mental patients
are best off in an institution especially built or adapted for their
requirements, under the care of skilled nurses especially trained
in the management of the insane and under the supervision of
medical men who have had a large experience of mental disorders
and have made them their special study. Owing, however, to
the way in which an ignorant public regards a person who has once
been under care in an asylum as somewhat of the nature of a freak
and stigmatizes him with such kakophemisms, if I may coin
a word, as ‘‘madman”’ and “ lunatic’’, the friends of the patient
are often anxious that the treatment should, if possible, be carried
out in a private house. The possibility of this course depends
partly on the nature of the disease and partly on the funds
539
540 MIND AND ITS DISORDERS
available for the purpose, treatment in a private house being
an expensive procedure. Symptoms which render asylum care
imperative in 99 per cent. of cases are homicidal and extremely
suicidal tendencies, great excitement with noisiness, persistent |
refusal of food and dirty habits.
When it is decided to carry out the treatment ina private house,
it is necessary to engage at least two nurses and sometimes,
according to the nature of the case, four or even six, who should
of course be selected on account of their having had abundant
previous experience of mental disorder, will consequently make
due allowance for the patient’s symptoms and not treat them
as inexperienced people do, as if they were a manifestation of
innate wickedness.
A suite of rooms, preferably on the ground floor, should be set
apart for the patient and his nurses and adapted so as to minimize
the risks attendant on the home treatment of mental disorder.
The nurses should have charge of the keys, stops should be placed
in the frames of the windows, a guard fixed round the fire, the
bolt removed from the door of the water-closet, and such orna-
ments and projections as the patient might use for self-injury
taken away. These precautions having been carried out the treat-
ment is otherwise much the same as in institutions for the insane.
Contraband of Lunaey.—All sharp-pointed and cutting instru-
ments such as knives, razors and scissors must be locked up
and all keys taken away. Experience teaches that Bibles and
Prayer-Books are usually a source of worry to a mind diseased,
instead of the comfort they should be. The physician will do
well to consider in each individual case, after an examination of
the patient, whether it will not be wise to make these books also
contraband. If it, be decided to forbid the use of Bibles and
Prayer-Books, the patient will also, of course, not be allowed to
attend church.
Chess is too severe a game for a person whose brain requires
rest and I recommend that sets of chessmen be forbidden to any
person suffering from acute mental disorder.
Flannelette night garments are to be disallowed for the reason
that flannelette is too inflammable, can be torn noiselessly under
the bedclothes and a strip of it used for suicidal purposes.
Bed.—It is best to commence the treatment of all cases of
insanity by a few days’ rest in bed. In chronic cases this gives
the physician an opportunity of making a complete mental and
physical examination of the patient and allows the nurses time
to make observations. In acute cases bed forms an important
THE PHYSICIAN’S BEHAVIOUR TOWARDS THE PATIENT SAT
item in the treatment. The value of bed-treatment has already
been insisted upon under the headings of the various diseases for
which it is desirable. It should be remembered, however, that
the habit of masturbation contra-indicates prolonged rest in bed
and that neurasthenics easily contract the ‘“ bed habit ”’.
The Physician’s Behaviour towards the Patient.—It should
always be borne in mind that nearly all patients suffering from
acute mental disorder are abnormally sensitive. Therefore, if
for no other reason, be kind to them and studiously avoid hurting
their feelings. Remember that ill-humour may be a symptom
of their disease and require treatment as such. Never allow
yourself to feel irritated by patients.
Most patients are aware that they require a strong, robust-
minded friend who thoroughly understands their weakness, on
whom they can rely for moral support and comfort and in whom
they can place implicit confidence; whether they know it or not,
the fact is so. The person who should occupy this position in
the patient’s mind is his physician. The latter should therefore
never deceive a patient. From the moment of his entry into
the institution, be frank with him. It often happens that a
patient is enticed into an establishment by means of some little
fraudulent device; he is, for example, told that the place is
an hotel and his physician is requested not to disillusion him;
but to do this would be to lose his confidence for ever. His
position should at once be frankly explained to him and sub-
sequent experience of his doctor be such as to teach him that he
is dealing with a straightforward man. Further, the doctor’s
examination must be thorough and of such a nature as to tell
him all about his patient and to let the patient see that he ©
knows all about him. Be interested in his conversation and
sympathetic, let the tale of woe be never so familiar. By such
means confidence will be won.
Lastly, be serious but cheerful. Moods are contagious and
words of comfort and encouragement are more readily accepted
by a patient if he is in a serious but cheerful mood. Suggestion
as to recovery is carried out by pointing out amelioration of
symptoms. Delusions should be listened to but not discussed,
it is foolish to argue with a patient about subjects in regard to
which his judgment is disordered. Probably the best attitude
to take up with regard to delusions is to let the patient know
that you are trying to see matters from his point of view but,
when an appropriate occasion arises and not one minute before,
to drop a hint that he may be mistaken.
542 MIND AND ITS DISORDERS
Occupation.—This is good for patients, provided it is not of
such a nature as to require strenuous physical exertion or mental
strain. At Bethlem Hospital many patients were at one time
taught to make baskets and wool rugs, mild occupations which do
not interfere with rest in bed. Sewing, knitting and the reading © |
of light literature are also permissible for acute cases. For
chronic patients who are capable of employment, regular daily
work is not only permissible but directly beneficial. In county
and borough asylums much useful work is done which serves to
keep down the rates.
Seclusion and Mechanical Restraint.—When a patient cannot
by persuasion be induced to remain in his room and to take his
rest, restraint becomes necessary. This may be accomplished
(1) by locking the door of his room (seclusion), (2) by a number
of nurses holding him or (3) by the administration of powerful
drugs such as hyoscine. Of these the last may be directly in-
jurious to the nervous system and is to be regarded as a refined
substitute for hitting the patient on the head with a club; the
second involves a resistant struggle on the part of the patient,
with consequent exhaustion; while the first involves nothing
more serious than keeping a record of the number of occasions
and number of hours during which the patient is secluded and
reporting the same to the Board of Control every three months.
There can be no doubt that seclusion is the least harmful
method of restraint. Out of common humanity it should be
resorted to as little as possible, for it is naturally somewhat irri-
tating to a patient to be locked in his room; but it is the least
of the three evils.
Mechanical restraint may be employed to hamper certain move-
ments of the body for surgical reasons or in order to prevent self-
injury or injury to others. The commonest form of mechanical
restraint and probably the only necessary form, apart from
splints for fractures etc., is the wearing of soft padded gloves
without fingers, in order to hamper prehensile movements. The
gloves are fixed by means of locked straps round the wrists.
This mode of treatment should also be resorted to as little as
possible, but it is less irritating than being held by the nurses.
As in the case of seclusion, all occasions of mechanical restraint
must be reported to the Board of Control.
Food and Feeding.—Loss of appetite is one of the commonest
symptoms in all acute forms of insanity, while overfeeding is
one of the most important indications in the treatment. All
food ought therefore to be of the best, nicely cooked, made as
FOOD AND FEEDING 543
palatable as possible and served in a dainty, enticing way.
Ten shillings or less per week per patient is not enough to spend
on food. Quite apart from our duty to the patients such
economy is a shortsighted policy which causes many to become
a life-burden on the rates. On a few occasions within the
author’s experience the Bethlem authorities have broken their
twelvemonth rule and admitted from county asylums cases of
apparently chronic mania and melancholia of more than three
years’ duration. By persistent good feeding and careful treat-
ment these have rapidly recovered.
As to the constituents of a good diet, much nonsense is talked
nowadays concerning what we should eat. An ordinary English
breakfast, dinner, tea and supper of good food in ample propor-
tions, amplified proportions for the acutely insane, serve their
purpose excellently well. The addition of three pints of milk
per diem, perhaps with superadded cream, may be regarded as
the specific medicine for these patients. A glass of wine with
meals often improves the appetite wonderfully and it has the
advantage of promoting absorption by the gastric mucous
membrane.
It is, of course, quite permissible to practise economy in the
feeding of those who have become chronic and undoubtedly
incurable. They do not need the extra food. Vegetative de-
ments who do no work require less than a normal individual.
Their taste is not refined and it can do no harm to supply
them with the cheapest food on the market, provided it is
wholesome.
In the ordinary way, patients who refuse food are to be fed
with a spoon by the nurses; but these should not be allowed
to pour fluid nourishment down the patient’s throat with the
feeding-cup, a pernicious utensil and a fertile source of pulmonary
abscess and gangrene.
If the refusal of food becomes so active that the nurses are
no longer able to administer sufficient nourishment by means of
a spoon, it is necessary for the patient to be tube-fed. Tube-
feeding is carried out in the following way: With a funnel
attached, a stiff indiarubber feeding-tube is passed into the
stomach, a No. 10 vid the nose or a No. 20 vid the mouth gagged
open if necessary. By this means the patient is fed with a pint
of milk, four ounces of cream, and two eggs. The process may
have to be repeated three or four times a day for months together.
Sleeping-draughts and aperients may be administered with the
food at the same time; it matters not how the mixture tastes
544 MIND AND ITS DISORDERS
when passed through a tube, for the patient is then unable eS
appreciate its flavour.
Some patients are able to prevent the fluid from entering the
stomach by keeping the abdominal walls tense. This difficulty
may be overcome by the use of a Higginson’s syringe, the nozzle
being inserted into the end of the feeding-tube, while the other
end lies in the food.
Care must be exercised to avoid all possibility of food enter-
ing the larynx during tube-feeding. If the patient regurgitates
gastric contents by the side of the tube into the pharynx, the
tube and gag must at once be withdrawn; for it is impossible
Fic. 86.—PROLONGED BATH.
The wooden cover, with an aperture for the head, is screwed on top of an
ordinary bath. This is, however, usually dispensed with nowadays.
for him to swallow the fluid under such circumstances and the
only other way of disposing of it is to inhale it. And in all cases
of tube-feeding, when the tube is withdrawn, be careful to keep
the funnel low so as to siphon the last few drachms of milk,
which may be left in the tube, away from the pharynx.
The indigestion of many patients who refuse their food may be
much ameliorated by stomach lavage with a dilute solution of
bicarbonate of soda, carried out daily as a preliminary to the
first feed every morning.
MEDICINES 545
Hydrotherapy.—This is useful mainly in three forms: the
prolonged bath, the douche and needle baths and the wet pack.
The prolonged bath has already been described in the treatment
of acute mania; it serves the purpose of inducing the habit of
rest in all cases of acute excitement. The douche and needle
baths often serve as a beneficial stimulus to certain stuporose
patients; they should not be employed if the patient suffers
from cyanosis or cedema of the hands and feet or before his
general nutrition has been considerably improved. A cold plunge
is often useful for acute confusional cases during convalescence.
The wet pack is a procedure to be employed only with the most
extreme caution and circumspection, since it is rather exhausting
and tends to raise the patient’s temperature. It is used to subdue
excitement of such a violent character as is likely to prove
dangerous, but should not be resorted to unless he is in fairly
good physical condition. It consists of wrapping him in a sheet
wrung out of water as hot as can be borne, and outside this is
a dry blanket. He remains in this sort of general fomentation
for about twenty minutes to half an hour, during which time it
is well to keep up a supply of cold applications to the head.
Medicines.—Of all the drugs employed in the treatment of
mental disorder hypnotics are those most frequently used. Their
name is Legion and I suppose that no physician has had ex-
perience of them all. Certainly I have not; but I give my
experience of the sleeping-draughts in most common use.
Paraldehyde is a drug which produces sleep within a quarter
of an hour and its effects pass off rapidly, within two hours.
It is therefore the drug which one selects for those patients
who have difficulty in getting off to sleep but whose sleep, when
once started, continues for a reasonable number of hours. Its
. nauseous flavour and the objectionable odour which it imparts
to the breath during the following day are its chief disadvantages,
but in some cases it also impairs the appetite and in others its
continued use is rather liable to induce a mild bronchitis. It is
a cardiac stimulant. The initial sleep is profound, sufficiently
so to allow of mild operations being painlessly performed on a
patient under its influence. The dose is 2 drachms, but double
that quantity may be administered without doing any harm.
Amylene hydrate acts even more quickly than paraldehyde.
Its effect is more prolonged (six to eight hours). It has the addi-
tional advantage of being less nauseous than paraldehyde. It
has a somewhat unpleasant camphoraceous taste, but this does
not hang about the mouth after the draught is swallowed. The
3,
546 MIND AND ITS DISORDERS
dose is 14 drachms in an ounce of water. Two drachms is too
large a dose, as the profundity of sleep then becomes rather
alarming.
Dial is a hypnotic made by the Clayton Company into
tablets. Its action is not quite so rapid as that of amylene
hydrate, but it is similar in other respects. One and a half or
two tablets is a suitable dose for most patients. It is my experi-
ence that, when the right dose for a patient is found, either a
greater or smaller one is less efficient. Dial restores the sleep
habit so effectively that gradual reduction of the doses causes the
patient little or no distress and this can easily be carried out
because the tablets are so constructed that they can be divided
into quarters. Clinically dial appears to be a pure hypnotic with
no other pharmacological action.
Veronal is a useful hypnotic for patients who procure sleep
of insufficient duration. If a patient, for example, gets four
or five hours without the use of drugs, veronal in doses of 7 or
8 grains will give him another two hours. If, on the other
hand, he procures very little normal sleep, veronal is useless
in such small doses; and if a dose sufficiently large to give him
a good night (14 or 15 grains) be administered, he is sick next
day. I have not experienced any other untoward results with
veronal.
Medinal (sodium-veronal) is a more certain hypnotic, gives
the patient more sleep, and does not produce sickness or other
troubles. It acts better with some people than with others and
it is often useful in allaying agitation. Some doctors give as
much as 30 grains without any obvious detriment, but I seldom
give more than 15 and usually prescribe 7 or 8 grains.
Soneryl (Butylethylmalonylurea) is the latest addition to this
group. Itis put up in tablet form. Ihave not much experience
of it so far, but it appears to be an improvement in that its
action is more rapid and lasting and it does not cause indigestion.
It is also said to alleviate pain. The most usually effective dose
appears to be two or three tablets.
Sulphonal still maintains an honourable place in the list of
hypnotics in spite of its tendency to produce haematoporphy-
rinuria on repeated administration for long periods. Its action
is delayed and it should therefore be given three or four hours
before bedtime. In some cases of obstinate insomnia it may not
act at all for the first two or three nights; but, after that, it
becomes more and more effectual. It has the advantage of being
a motor sedative and is therefore almost a specific for acute
MEDICINES 549
mania. For the prevention of hematoporphyrinuria and to aid
the action of the drug it is recommended that its administration
be followed by a draught of Contrexéville water. Sulphonal
tends to produce irritability of temper in some young patients,
but it usually suits old people. The usual dose is 20 to 30 grains.
Isopral in doses of 20 to 30 grains is a good hypnotic and a
motor sedative. It has none of the bad after-effects of sulphonal;
but it must be borne in mind that it is a vesicant, and should
not be given in water. It is best administered in a teaspoonful
of jam.
Lrional is in my experience a poor hypnotic for insane patients
and I have entirely discontinued its use since Soukhanoff stated,
in a paper on degeneration of the neuron in animals, that he
found this to be the most effective drug for producing neuronal
degeneration.
Chloralamide, too, I regard as practically useless for the insane;
but it may be helpful to neurotic patients.
Chloral hydrate is a good hypnotic which acts quickly and has,
as a rule, no bad after-effects. It is suitable only for depressed
patients since it has a tendency to increase motor excitement.
It does not find much favour among physicians who have to
treat the insane, because its depressing effect on the heart and
respiration 1s somewhat dreaded.
Opium is still one of the best hypnotics we possess and it, or
its alkaloid morphia, may have a beneficial effect on the nervous
system in some agitated cases of melancholia. Indeed, at one
time doctors used to talk of the “opium treatment of melan-
cholia ’’, as if they had found a specific remedy for that disorder.
The drug does not, however, find much favour as a hypnotic for
the insane, partly because opium makes many of these patients
sick, but chiefly because it increases constipation, which is already
troublesome enough among these patients.
Other medicines required in the treatment of mental patients
are those used to build up the general health. Anemia, constipa-
tion and indigestion are to be treated on general medical prin-
ciples, the discussion of which would be out of place in a manual
of this nature.
Masturbation is a symptom which often requires treatment.
Devices for its prevention have been invented from time to time,
but none of them serve their purpose, for the reason that they
attract the patient’s attention to the very part which already
dominates his consciousness too much. The best sexual sedative
for the masturbator and one which often serves to break the habit
548 MIND AND ITS DISORDERS
is an emulsion containing a drachm of the extract of black willow
and 5 grains or more of monobromate of camphor and of sodium
bromide to each dose. This may be given three times a day after
meals. Extract of Jamaica dogwood is also recommended.
In out-patient practice at St. Thomas’s Hospital I find that
sodium bromide is a helpful drug to most neurotic and psychotic —
patients. The usual dose is about Io grains three times a day
with a couple of minims of liquor arsenicalis to prevent a bromide
rash. As we have seen in earlier chapters, many neurotic
symptoms are a distorted method of gratifying some unrecognized
perverse sexual complex and I hold the view that the beneficial
action of the bromides is due to the fact that they are an-
aphrodisiacs.
Prevention of Suicide.—There is only one means of preventing
suicide, viz., constant observation. The physician learns by
experience to recognize which patients are suicidal and which
may be trusted and he must tell the nurses. clearly when a
patient is suicidal and not to be allowed out of sight. Some very
suicidal cases require the whole attention of one or more nurses.
Patients must not be allowed access to dangerous weapons or
articles with which they can strangle themselves, and the fire
must be protected. Apart from such precautions as these, we
have to rely on the intelligence of the attendants and it should
be the object of all institutions to increase the intelligence of the
nursing-staff by instruction and by the removal of those who are
incapable of instruction and learning from experience. The
writer is strongly opposed to the practice of making rooms and
wards in which patients have to live for long periods of their lives
unsightly and prison-like with the object of doing away with
every conceivable means of suicide. For one thing this cannot
be done and, for another, it tends to decrease the sense of
responsibility of the personnel.
Visits and Letters from Friends.—A difficulty which often arises
in the treatment of the insane is interference on the part of the
friends of the patient. It is with the utmost difficulty, in the
majority of cases, that these can be made to realize that mental
disorder is a definite disease and they believe themselves, in
common with the rest of mankind, to be perfectly qualified to
treat insanity.* For them any person suffering from mental
disorder is either an imp of wickedness or a lazy scoundrel and
* Many physicians qualify themselves for this work by saying that they
treat only borderland cases. If they adhered to this principle and referred
their mental cases to a medical psychologist, which they do not, incar-
ceration in an asylum might more frequently be averted. “
CONVALESCENCE 549
they have no patience with any person who is “ fool ” enough to
believe things which are manifestly untrue.
Accordingly they seize upon the opportunity of their visits to
scold the patient for daring to be depressed or excited and to
threaten him with imprisonment for life or something worse by
way of an antidote to his delusions. Letters are no better.
Instead of words of encouragement they contain threats of
desertion and of other dire consequences in the event of the
patient persisting in his delusions. Of course such methods are
most detrimental to his progress and if, after due explanation
and warning, his “ friends ”’ continue to worry him in this way,
there is no other course open to the physician than to put a stop
to visits and letters. Fortunately, the friends of the patients
are not all so foolish, and some do a great deal of good. I regret
to say that this is the exception. An observant physician will
soon learn which patients are worse after ‘‘ visiting-day ’’ and he
will act accordingly. Matters are even worse when the patient
is being nursed at home. The work of the nurses is usually
rendered extraordinarily difficult on account of suspicion. What
the relatives or friends suspect I know not and it is certain that
they themselves do not know.
In institutions also the friends are often suspicious that there
is something sinister in the treatment of the patient; they will
examine and cross-examine the doctor, the matron, the sister
of the ward, the nurses and even other patients respecting the
treatment in general and that of the patient in whom they are
interested in particular. Should any discrepancy transpire it is
clear evidence that some underhand business is being concealed;
then there is trouble. In any other situation the person in authority
would insist on the removal of the patient, but here it would not
be fair to the patient—it would be bad treatment. Bearing such
considerations in mind, the doctor has to exhibit much tact and
discretion in solving individual problems in the best way.
Convalescenee.—When convalescence is established, the patient
may attend “ associated entertainments ’’ and be encouraged to
take exercise. He is allowed to go out for walks, at first with
a nurse, then with his own friends if they are trustworthy. Later
he may be permitted to go for walks by himself, after having
given his word (‘‘ parole ’’) to return to the institution at a given
time and to abide by any restrictions which the physician may
think wise to bestow on him. Finally, before leaving the insti-
tution, the doctor should advise him as to his subsequent mode
of life with a view to preventing the recurrence of his disease.
CHAPTER XXEX:
THE INSANE AND THE LAW.
[The revision of this chapter for the present edition has been kindly
and very thoroughly carried out by W. H. Gattie, Esg., K.C.]
In the majority of cases of mental disease the patient either has
no insight into the nature of his condition or, if he has, is un-
willing or unable to make up his mind to place himself under
care and treatment. Accordingly it becomes necessary for his
friends or relatives to place him under care against his will,
either in his own interest or for the sake of the public. Now
the law will allow such trespass against the liberty of a subject
under certain conditions only. These will be considered in the
present chapter and we shall further have to study the extent to
which the law will allow a patient mentally diseased to exercise
certain civil rights and how far it will excuse him from his civil
and criminal responsibility.
The carrying out of the Lunacy Acts and Mental Deficiency Act,
so far as concerns the care and treatment of patients, is largely
entrusted to a Board of Control consisting of a Chairman, Secre-
tary and not more than fifteen Commissioners, two of whom are
ladies. The Secretary and four of the Commissioners must be
barristers or solicitors and at least four are medical men.
All institutions for the reception of patients suffering from
mental disease who, under the law, are spoken of as “‘ Lunatics ”’,
‘“ Persons of Unsound Mind ”’ (non compos mentis) or “‘ Mentally
Defectives’”’ are under the jurisdiction of the Board of Control.
These institutions are of four classes:
1. Licensed Houses.—Fach of these is the property of one or
more private individuals or private limited company who for
a fee (£15 or more annually, according to the number of patients
accommodated in the institution) obtain for their house a licence
which must be renewed from year to year. To comply with the
law one of the licensees must be resident in the house. In
London and a specified surrounding area such institutions receive
at least six visits every year from the Commissioners. Outside
this area licensed houses receive annually two visits from the
55°
ESTABLISHMENTS FOR THE INSANE Gov!
Commissioners and four from justices of the peace appointed
under the Lunacy Act.
The friends of the patient pay for his maintenance in the
institution, the fee varying usually from three to twelve guineas
weekly according to his requirements. In the grounds of some
licensed houses there are suitable villas where a patient may be
treated and attended by a complete staff of nurses and servants;
under such circumstances the weekly payment reaches £50 or
more.
2. Registered Hospitals are self-supporting and usually en-
dowed institutions for the treatment of private patients, the
funds being under the control of a committee of visitors. Fees
from paying patients are utilized purely for the maintenance
of the hospital and not for the personal profit of any private
individual. Hospitals in Home Counties are visited twice a
year by the Commissioners, those in the provinces once a year.
Annual registration is not required.
3. Public Asylums (now generally described as Mental Hospitals,
but which must not be confused with the Registered Hospitals
described in the preceding paragraph).—These are the county
and borough asylums erected and maintained out of the rates
for the treatment of pauper lunatics; the State Criminal Asylum
at Broadmoor, erected and maintained by the State, the patients
being paid for out of the rates of the borough or union to which
they are chargeable; also the Royal Military Hospital at Netley
and the Royal Naval Hospital at Great Yarmouth, both erected
and maintained by the State. Some of the county and borough
asylums receive a few private patients and all of them, as well
as the registered hospitals and even licensed houses, may receive
“ criminal lunatics ’’. All public asylums are visited once a year
by the Commissioners.
4. The various Institutions and Approved Homes etc., under
the Mental Deficiency Act, for the reception and treatment of
idiots, imbeciles and other classes of the mentally defective. To
accommodate the large class of people who are anxious tb spare
their friends and relations the stigma of detention in an asylum,
registered hospital or licensed house, the law allows one insane
patient to be detained and treated in a private dwelling for profit,
provided he is certified and reported to the Commissioners in
Lunacy. Under such circumstances the house is liable to be
visited by one of the Commissioners at any reasonable time, when
he must be afforded facilities for seeing any part of the house.
More than one certified patient in a private dwelling is disallowed,
552 MIND AND ITS DISORDERS
unless the Commissioners grant a special permit for the reception
of two or more such patients.
A patient suffering from uncertifiable mental disorder may
voluntarily place himself for treatment in any house or institution
whose occupants are willing to receive him for profit; and a
certifiable patient may be detained and treated under the com-
mon law (7.e., uncertified) against his will in any house or insti-
tution whose occupants are willing to receive him, provided
this is not done for profit. Although a person receiving a
patient under such circumstances is not liable under the Criminal
Law, it must not be forgotten that he runs the risk of a subse-
quent civil action brought against him by the patient. The
position of affairs is that it is only safe to detain an uncertified
patient under such circumstances when he is dangerous either
to himself or to others, and then merely as a temporary measure
pending certification.
There is no provision at present for voluntary boarders in
public asylums, but an uncertifiable patient may place himself
for treatment in a registered hospital or licensed house on the
understanding that he may be allowed to leave within twenty-
four hours of giving notice to do so. In the case of a licensed
house the intending boarder must first obtain from the Board of
Control (or two local justices if the house is in the provinces)
their consent, which may be given for a specified time only. It
is not necessary for intending voluntary boarders in licensed
hospitals to apply to the Board of Control. After the admission
of a voluntary boarder, notice of the same must be sent to the
Board of Control within twenty-four hours.
The following are the modes of procedure by which a patient
may be placed under care, usually against his will:
1. Reception Orders on Petition.
2. Urgency Orders.
3. Summary Reception Orders for
(a) Lunatics wandering at large.
(b) Pauper Lunatics.
(c) Lunatics who are not under proper care and control or
are being cruelly treated or neglected.
4. Reception Orders by a Commissioner to the Board of Control.
5. Reception Orders by the Home Secretary (used in criminal
cases, vide p. 565).
6. Orders after Inquisition.
Reception Orders on Petition.—This is the ordinary mode of
procedure for private patients. The necessary documents are a
MODES OF PROCEDURE AS
petition, statement of particulars, two medical certificates and
an Order.
The Petition is a document asking some particular County
Court judge, stipendiary magistrate or justice of the peace
(specially appointed under the Lunacy Act) to make an order
for the reception of the patient into a particular asylum, hospital,
licensed house or private dwelling. It must be signed, whenever
practicable, by the husband, wife or a relative of the patient,
who must have seen him within fourteen days of the presentation
of the petition. If any other person sign the petition, the reason
must be given. In any case the petitioner must be above twenty-
one years of age.
The Statement should also be signed by the petitioner, but if
it is not so signed, any other person is eligible to sign it, provided
details of address, occupation and conditions under which such
person signs are inserted where indicated on the form. It con-
tains particulars as to the name, age, sex, civil state etc.
One of the medical certificates must, whenever practicable, be
signed by the usual medical attendant, unless he be related to the
patient or the petitioner. Neither certificate may be signed by
(1) The manager of the institution receiving the patient or the
person who is to have charge of a single patient;
(2) Any person interested in the payments on account of the
patient;
(3) Any regular medical attendant of the institution ;
(4) The husband or wife, father or father-in-law, mother or
mother-in-law, son or son-in-law, daughter or daughter-in-law,
brother or brother-in-law, sister or sister-in-law or the partner or
assistant of any of the foregoing persons.
If it be desired that the usual medical attendant continue to
attend the patient, it is held by the Board of Control (but their
opinion may be disputed) that neither he nor his partner may sign
either of the certificates; he must certainly have no monetary
interest in the house to which the patient is sent.
The medical practitioners signing the certificates must, for
purposes of certification, examine the patient separately and at
a time not exceeding seven clear days before the presentation of
the petition to a justice.
The certifying practitioner is required to state facts observed
by himself at the time of examination and he is at liberty to add
facts communicated by others. He should confine his statement
to facts which, considered either individually or in relationship
to one another, are such strong evidence of insanity that he
554 MIND AND ITS DISORDERS
would be willing to be cross-examined on them in a court of law.
Irrelevant statements, expressions of opinion and records of
physical signs should find no place in a certificate. For example,
the following, culled from the certificates at Bethlem, should
have been omitted: ‘‘ His demeanour indicates an unhinged
mind ”’; “‘ Wild look in his eyes ’’; “‘ Speaks lucidly at intervals ”’;
“ Patient’s tongue is tremulous and his articulation is indistinct ”’;
“ Patient says I am a fool”’. } 3
No medical man is bound to sign a certificate; but, if he does
so, he must remember that any wilful misstatement is a mis-
demeanour. If he acts in good faith and with reasonable care
he is not properly liable to any civil or criminal proceedings.
If such proceedings are taken against him, they may be stayed
on summary application to the High Court, provided that the
Court is satisfied that there is no evidence either of lack of good
faith or non-exercise of reasonable care.
The Order, authorizing some person to receive the patient into
his institution or house, may be signed by a judicial authority
(t.e., a judge of a County Court, a stipendiary magistrate or a
justice of the peace specially appointed under the Lunacy Act,
1890) with or without seeing the patient, after he has perused
the petition, statement and certificates.
Should the judicial authority wish to see the patient before
signing he must appoint a time within seven days for doing so.
Having seen him he may either sign the order forthwith or again
postpone the matter for a period not exceeding fourteen days.
When a patient is admitted to an institution or house without
having been seen by a judicial authority the superintendent or
medical attendant must give notice in writing to the patient that
he has a right to be visited by a judicial authority and, if the
patient desire it, cause a judicial authority to visit him; or, if
the medical attendant considers that this would be prejudicial
to the patient, he must send to the Board of Control a certificate
to this effect. In practice the judicial authority is nearly always
a justice of the peace, but he must not be the judicial
authority who signed the Reception Order for the patient’s
detention.
It is obvious that the above procedure, even at the shortest,
takes some considerable time, probably two or three days; but
in certain cases, especially those in which the patient is dan-
gerous to himself or others, it is desirable that he should be
placed under care forthwith. This may be done by making use
of the Urgency Order.
THE JUSTICE’S ORDER DDD
Urgeney Orders.—In this mode of procedure no petition is
necessary; authority to receive the patient is granted, whenever
practicable, by the husband or wife or a relative of the patient.
When it is granted by any other person the reason for the de-
parture must be given. The person signing the order must
have seen the patient within two days of his admission to the
institution. The order must be accompanied by a statement of
particulars, similar to that accompanying a petition, and by one
medical certificate. The certifying medical practitioner must
have seen the patient within two clear days of his signing the
certificate. This certificate differs from the ordinary schedule
form in that it must contain a clause giving the reasons for
urgency. An Urgency Order remains in force seven days, or if
a petition for a Reception Order is pending, until the petition is
finally disposed of. In practice a Reception Order on Petition
has to be completed within seven days of the signing of the
Urgency Order.
Summary Reception Orders.—Every constable, relieving officer
or overseer of a parish, who has knowledge that any person within
his district, who is not a pauper and not wandering at large, is
deemed insane and is not under proper care and control or 1s being
cruelly treated or neglected, shall within three days give information
on oath to some judicial authority under the Lunacy Act, usually
a justice of the peace. The justice shall then direct two medical
practitioners to examine the patient and certify as to his mental »
state. If these certify that the patient is insane and a proper
person to be detained under care and treatment, the justice may
sign an order for his removal to a house or institution for the
insane. The documents used in this mode of procedure are the
same as those for a Reception Order on Petition, except that there
is no petition.
Orders for Pauper Lunatics and Lunatics wandering at Large.—
The law enacts that such persons be apprehended by the local
constable, relieving officer or overseer of the parish and that
they be taken before a justice. In practice the patient is taken
to the infirmary of the union in which the patient is apprehended
and is there visited by a justice. If the justice considers the
patient to be insane, he directs that he remain under observation
in the infirmary for a period not exceeding fourteen days. H,
at the end of this time, he considers the patient still insane,
he directs a medical practitioner (usually the medical officer
of the infirmary) to examine the mental state of the patient.
If the medical practitioner certifies that the patient is insane,
556 MIND AND ITS DISORDERS
the justice makes an order for his reception into an institution
for lunatics, unless the medical officer certifies in writing that
the patient is a proper person to be detained as a lunatic in a
workhouse. It will be observed that only one medical certificate
is necessary in the case of pauper lunatics and lunatics found
wandering at large.
Order by a Commissioner.—Any one or more Commissioners
may visit a patient, not in a workhouse or institution for lunatics, —
call in a medical practitioner and, if he certifies the patient to be
insane, order him to be removed to an institution for the insane.
Orders after Inquisition.—A person found lunatic by inquisition
may be received on an order signed by a Committee of the
person of the lunatic, or if no Committee has been appointed,
then on an Order by a Master in Lunacy.
Judicial Inquisition as to Lunacy.—The Judge in Lunacy
may, upon application, by order direct an inquisition whether a
person is of unsound mind and incapable of managing himself
and his affairs. The patient may claim and is entitled to be
examined before a jury. The inquiry is limited to things said
and done by the patient within two years of the inquisition.
The chief witnesses are medical men including those who have
signed certificates and affidavits with regard to the mental con-
dition of the patient and usually others who may be called as
expert witnesses for both sides. These are examined and cross-
examined on oath before a judge or Master in Lunacy, either in
open court or in private, just as in an ordinary trial.
The jury may return one of three verdicts:
1. That the patient is capable of managing both himself and
his affairs.
2. That he is incapable of managing either himself or his
affairs.
3. That he is capable of managing himself but incapable of
managing his affairs.
The contingency of a person being capable of managing his
affairs but not himself does not occur. If the jury find ver-
dict (2), the Master in Lunacy appoints a ‘“‘ Committee of the
Person’”’ and a ‘‘ Committee of the Estate’’, who may be one
and the same person. The patient is thenceforth known as a
“Chancery lunatic’”’ and he is regularly visited by one of the
Lord Chancellor’s visitors, one of whom is a barrister-at-law and
two are medical men. If verdict (3) is returned, the Master
appoints a “‘ Committee of the Estate ”’ but not a “‘ Committee of
the Person ’’; and the patient is free to go about as he chooses.
MENTAL DEFECTIVES 57
In practice, an Inquisition in Lunacy is now almost obsolete.
This change came about owing to the operation of the Lunacy
Act, 1908, which conferred upon a “ Receiver ’’ the same powers
as to management of property as was previously vested in the
Committee of the Estate. The person appointed as a Receiver
is generally a near relative of the patient, but he should not be
in any fiduciary relationship. If no desirable relative is available,
or if no intimate friend comes forward and applies to be appointed,
the Official Solicitor to the Royal Courts of Justice is generally
called upon and duly appointed. The appointment of a Receiver
is far less costly than an Inquisition in Lunacy.
The procedure for placing a mentally defective person under
care in an institution or house approved for mentally defectives
is similar to the Reception Order on Petition under the Lunacy
Acts, with two important differences. One is that the petition
must be accompanied by a Statutory Declaration by the parent
or guardian and some other person that
(1) The patient is a defective within the meaning of the Act
(the Mental Deficiency Act, 1913).
(2) He is subject to be dealt with under the Act by reason
of certain specified circumstances.
(3) A petition has or has not been made under the Lunacy Acts.
(4) A medical examination is impracticable, the reasons being
given.
The other difference is that one of the medical certificates must
be made, not necessarily by the usual medical attendant of the
defective, but by a medical practitioner in possession of a certi-
ficate of approbation under the Act, either by the local authority
or by the Board of Control.
In the case of feeble-minded persons and moral imbeciles
over twenty-one years of age, a full Reception Order on Petition
is required; but no Order by a Justice is required for an idiot
or imbecile of any age. Procedure is therefore simplified if the
doctor can certify that the patient is an imbecile, rather than
a feeble-minded person.
The wording of the schedule differs but slightly from that of
the Lunacy Acts.
Returning to the subject of the detention of persons of unsound
mind under the Lunacy Acts, the following particulars must be
observed :— .
Within one clear day of the reception of any patient into an
558 MIND AND ITS DISORDERS
institution or private house notice of the same must be sent to
the Commissioners, together with a copy of the admission
papers.
Not less than two days and not more than seven clear days
after the reception a medical statement as to the mental and
physical condition of the patient must be forwarded to the Com-
missioners. Another similar report must be sent at the expira-
tion of one month. In the case of patients in single care such a _
report is also required by the Board of Control during the week
following January Io in each year.
A Reception Order expires at the end of one year from its
date. If it is desired to keep the order in force for a further
period, a special report as to the mental and physical condition
of the patient must be sent to the Board of Control not more
than one month or less than eight days before the expiration of
the Order, together with a certificate that the patient is still of
unsound mind and a proper person to be detained under care and
treatment. Similar reports and certificates must, if necessary, be
sent at the expiration of the second, fourth and seventh years
and, after that, every five years.
These continuation certificates are not required in the case of
criminal patients detained by order of the Home Secretary.
The regulations with regard to these certificates are varied in the
case of ‘‘ Lunatics so found ’’ (Chancery Patients).
When a patient recovers or is otherwise discharged or removed,
notice must at once be sent to the Board of Control.
The manager of an institution may, if he think fit, grant
forty-eight hours’ leave of absence to any patient under his care.
For longer periods permission is granted by the Committee of
Visitors in the case of registered hospitals and public asylums,
by the Board of Control in the case of licensed houses within their
immediate jurisdiction and by the justices in the case of licensed
houses in the provinces.
Transfer.—No certified private patient may be transferred
from one institution to another without the consent of the Board
of Control. The Board has the power to allow the transfer of a
patient from a public asylum to a licensed house and from the
pauper to the private class. It will be seen that, in such circum-
stances, a private patient may be detained on one medical
certificate.
Escape.—If a patient escape, he may be recaptured at any
time within fourteen days and detained on the original order
and certificates. In the case of a Chancery patient notice of
LEGAL CAPACITIES AND RESPONSIBILITIES 559
such escape should be sent to the Lord Chancellor’s Visitors.
It is no longer necessary to notify an escape to the Board of
Control. .
LEGAL CAPACITIES OF THE INSANE.
1. As Witnesses.—As a general rule the insane are regarded as
incompetent to give reliable evidence; but the law allows the
presiding judge to decide the matter in each individual case and
it is left to the jury to determine how much importance they will
attach to the evidence of an insane person.
In the case of written evidence (affidavits) a preliminary
inquiry must be held to determine whether the person’s insanity
is of such a nature as to render unreliable his evidence upon the
particular matter under consideration.
2. As Testators.—For a will to be valid the law requires the
testator to have a “sound disposing mind”’ either at the time
when he gave instructions for the will to be prepared or at the
actual moment of its execution; it is not necessary that he
should have a “ sound disposing mind ”’ on both occasions.
It is immaterial whether the testator is a person “so found ”’
as a lunatic or not. If he be his capacity varies from other
insane persons, when dealing with the law of contract only.
The reason is that a will operates after the death of the testator,
when the Lord Chancellor’s control has ceased to exist, whereas
the operation of a contract comes into being iter vivos during the
Lord Chancellor’s control.
It often falls to the lot of a medical man to examine a patient in
order to decide whether he is of a sound disposing mind. When
called upon to do so he should make written notes of the examina-
tion; and he should endeavour to ascertain
(a) Whether the patient understands the nature of the will;
(6) Whether he understands the nature of the gift;
(c) Whether the patient is capable of enumerating, on the one
hand, the details of his estate and, on the other, the individuals
who have any reasonable claim to benefit from it ;
(d) Whether there appears to be any person who has exercised
undue influence on his decision ;
(e) Whether the patient is suffering from any delusion which
might influence his decision and whether he has any insane
dislike to or suspicion of any member or members of his family,
who might in the ordinary course become beneficiaries ;
(f) Whether he has any delusion respecting his property, which
might influence his decision ;
560 MIND AND ITS DISORDERS
(g) Whether, having once announced his decisions, he is
capable of recapitulating them, say a few days later.
These are the main points upon which the medical man will be
cross-examined should he be called upon to give evidence when
the will is disputed.
The law upholds a will made from eccentric, frivolous or
Capricious motives, provided it can be shown that the will repre-
sents the true wishes of the testator and was not the result of —
an eccentricity, frivolity or caprice of the moment amounting
to such a state of unsoundness of mind as would deprive the
testator of his testamentary capacity.
It is the rule at law that an idiot cannot make a will, because
he has no disposing mind—an imbecile “may” have a dis-
posing mind, but generally he would not be so regarded. There
are many forms of imbecility, but there is only one form of
idiocy. It is here convenient to state that whilst the law regards
an idiot as irrecoverable, such a principle is not applied to insanity.
CIVIL RESPONSIBILITIES OF THE INSANE.
Contracts.—The occurrence of insanity does not excuse the
patient from the performance of a contract made previously
to his becoming insane.
Contracts for “‘ necessaries ’’ made by an insane person may
be binding. By the term “ necessaries ’’ is meant such articles
as clothing; but the term is an elastic one and it is left to the
judge and jury to decide what articles are “‘ necessaries ’’.
An insane person, not so found by inquisition, or a person
who is drunk may make contracts for other than necessaries.
These may be binding unless the contract is of such a nature
that it would not have been made but for the unsound mental
condition at the time of making the contract. Even in such a
case the validity of the contract might depend, either upon the
knowledge of the insanity by the other contracting party, or of
the presumption of knowledge which such other party might be
held to have.
On the other hand a contract is frequently binding on the
second party whether he knew of the insanity or not, except in
the case of a marriage contract. In the latter case the Divorce
Court will grant a decree of nullity of marriage on application
of the second party provided it can be shown that he was not
aware of the insanity at the time of the marriage. Insanity
occurring subsequently to marriage is no ground for divorce.
)
CRIMINAL RESPONSIBILITY 561
It may be well to add, that the existence of delusions, even if
such delusions are known as such, to the other contracting party
will not necessarily invalidate a contract, unless such delusions
are held to extend to the root of the contract.
The decided cases with regard to the contracts of insane persons
present so many points for discussion, that it is here impossible
to attempt to give a full explanation of the legal intricacies with
which the question abounds. Suffice it in conclusion to say that
generally the law demands a higher capacity of understanding
in the execution of a deed than in a case of a simple contract,
more especially so in cases where the deed is contrary to the
interests of the insane person.
Torts.—A “tort’’ is an injury to the person, property or
reputation of another, which renders the offender liable under
the civil law but not necessarily under the criminal law. Libel
and slander may be cited as examples of torts. Libel may under
certain circumstances be punishable under the criminal law.
Adultery also is a tort, because it is a wrong to the other party
to the marriage. Theft, embezzlement, rape and murder are
not torts; they are crimes.
In English law insanity is not necessarily an excuse for a civil
wrong. The injured party may be entitled to damages on the
principle that every man is entitled to possess inviolate his
personal security, liberty, property and reputation. The amount
of damages is, however, left to the discretion of the jury and it
is not likely that they will award heavy damages, say, in a case
of slander in which the offender is known to be so insane that
nobody would attach any importance to his statements. Every
medical officer of a large institution for the insane is slandered
by patients every week of his life, but such slander does him no
harm, and an action for damages would be an absurdity.
CRIMINAL RESPONSIBILITY.
When a man commits a crime the law may demand that he
shall be punished; but if the act was committed as the result of
the direct action of another without any condition of mens rea
on the part of the person committing the act the law is that this
latter person who criminally started the train of circumstances
which led up to the act, is responsible for the crime and must
therefore be punished. This principle is well illustrated by the
following extreme case which, although dealing with the law of
torts, illustrates a principle of law which is convenient to quote
cp 3
562 MIND AND ITS DISORDERS
In a certain market-place a man threw a lighted squib on to a
stall, whose owner immediately threw it away so that it fell by
accident on another stall. The owner of the second stall also
threw it away and in so doing hit the plaintiff in the face and,
the squib thereupon bursting, the plaintiff's eye was put out.
It was held that the man who originally threw the squib was
answerable to the man whose eye was put out, the ground for
this decision being that he intentionally did an illegal and
mischievous act which was likely to prove injurious to others,
and must accordingly be held responsible for the direct and
natural consequences which resulted from what he did, whether
he actually intended them or not, and that the intermediate
parties acted by necessity imposed on them by the defendant.
Bearing this principle in mind, I suggest that a man who
commits a crime as an indirect result of disease is not to be held
responsible at law for his action. In this suggestion I am merely
going a little farther back than the legal explanation—the lack
of mens rea. The disease is in reality the responsible agent;
accordingly the law deals leniently with a person who has com-
mitted a crime but is proved to have been insane when he did it.
At a time when public feeling was running high on account
of the acquittal of one McNaghten who in 1843 shot Mr. Drum-
mond, the private secretary of Sir Robert Peel, supposing that
Mr. Drummond was Sir Robert Peel himself, whom the murderer
wildly suspected of having some connection with an imagined
system of persecution against him, the House of Lords summoned
all the judges and put to them a series of questions. The
answers to these constitute the highest expert legal opinion
which has ever been obtained on the criminal responsibility of
the insane. This opinion may be expressed as follows: If a
person suffers from a delusion but is not otherwise insane, he is
to be held responsible and punishable for his offence, unless he
has acted in such a way as would have been permissible, had the
facts about which his delusion exists been true. For example,
if a man kills another whom he believes to be about to kill him
(z.e., in self-defence), he is not to be held responsible; but if he
kills another whom he believes to be robbing him, he is to be
held responsible and punishable. In other cases it must be
clearly proved, to establish a defence on the ground of insanity,
“that, at the time of committing the act, the party accused
was labouring under such defect of reason, from disease of the
mind, as not to know the nature and quality of the act he was
doing or, if he did know it, that he did not know he was doing
CRIMINAL CASES 563
what was wrong’’. The above is an authoritative expression of
opinion on the way in which the law should be administered,
and the judges of the present day, while they do not all consider
the answers of the judges in 1843 as binding, find in them a
sound working basis for their administration of the common law.
In the light of experience these rules, so far as they go, seem
very fair and just. It would certainly be an erroneous principle
to make every form of insanity an excuse for crime. Everybody
with a large experience of the insane knows that many of them
take an unfair advantage of the fact, which they very soon
learn, that they are immune from punishment and other natural
consequences of their actions, so long as they remain in an
institution for the insane. It would probably be wrong, for
example, to allow a simple maniac who had shot his father to
go unpunished: but if a person suffers from the delusion that his
father is in imminent peril of undergoing some excruciating
torture and kills him with the object of sparing him that torture,
he is not to be held responsible for his action; because, at the
time of committing the act, although he might know that what he
was doing was legally wrong and punishable, he would consider
that he was doing what was morally right. This point must be
borne in mind by medical witnesses when they are asked, as they
always are, whether the prisoner was capable of distinguishing
right from wrong. The question does not mean “ Was the
prisoner capable of distinguishing what is legally right from
what is legally wrong ?’”’ It means ‘“‘ Was he capable of distin-
cuishing what is morally right from what is morally wrong ?”’
Again, the question does not refer to the prisoner’s general know-
ledge of right and wrong; it refers to his knowledge of right and
wrong in respect to the very act with which he is charged. Asa
matter of fact, the legal view of the above situation would be that
the state of mind of the accused should be such as to justify the
Court in excusing him from the penalty of his crime.
The answers of the judges do not, however, in my opinion go
quite far enough. They take no account of certain forms of
mental disorder which, in the opinion of medical men, should
excuse a prisoner charged with a crime from punishment. In
particular, they take no account of the various morbid impulses
occurring, for example, in the obsessional neurosis and in some
forms of senile degeneration. Indeed, cases have actually occurred
in which an old man, previously of high moral character, has
been sentenced to a long term of imprisonment for some im-
pulsive sexual offence, actuated by an incipient senile dementia
564 MIND AND ITS DISORDERS
(and also perhaps some irritation of an enlarged prostate), which
could not be controlled by a brain whose degeneration is only
too well confirmed by the subsequent history of the case. Apart
from other considerations, prison life can hardly be regarded as
a curative measure for such patients.
I have had under my care several patients who came to Bethlem
as voluntary boarders to be cured of a constantly recurring
impulse to kill their children. Some of these have told me that
if, by some mischance, one of their children had suddenly ap-
peared in close proximity when they had happened to have a
hatchet or a knife in hand the child would certainly have been
killed before the parent could have had time to realize the awful-
ness of his crime. Had such a thing actually happened, as it
sometimes does, the man might, according to the existing state
of the law, have been hanged.
These morbid impulses have not, however, entirely escaped
recognition by the Bench. Sir James Stephen expressed the
opinion that the McNaghten case admitted as a further exemp-
tion that “‘a person should not be punished for any act when
he is deprived by disease of the power of controlling his conduct,
unless the absence of control has been caused by his own default ”
(I presume that this refers especially to alcoholism); and his
opinion has been supported by the dicta of some other judges
(four cases). The view is also substantially adopted in the
Queensland Code of 1899 in the following clause: ‘‘ A person is
not criminally responsible for an act if at the time of doing the
act he is in such a state of natural disease or natural infirmity
as to deprive him of capacity to understand what he is doing
or of capacity to control his actions.”’
In the absence of legislation to the contrary, Courts of Law
are not precluded from recognizing the existence of a form of
mental disease which prevents the sufferer from controlling his
conduct and choosing between right and wrong, although he may
have the mental capacity to distinguish between right and wrong.
In murder cases the medical expert seldom has an opportunity
of examining the prisoner before he has been committed for
trial. When the opportunity occurs, the expert should take
down in writing everything the prisoner says, preferably in his
presence.
The magistrates, if they find evidence of guilt on the part
of the accused, are bound to send him for trial; they have no
power to discuss the question of sanity or insanity. Similarly,
whenever there is any evidence of guilt, the grand jury are
CRIMINAL CASES 565
bound to find a “true bill’; they have no power to ‘‘ cut the
bill” on the ground of insanity.
When it is intended to set up insanity as a defence, arrange-
ments are made for the medical witnesses to have one or more
personal interviews with the accused. At these interviews they
should take down in writing everything the prisoner says, prefer-
ably in his presence. The Court always allows a medical expert
to refer to such notes when giving his evidence, which must, of
course, be quite impartial.
In the High Court the question of insanity may be raised
either on arraignment or during the course of the trial. On
arraignment the jury may be asked (1) whether the prisoner is
“able to plead or not”’, (2) whether he is “sane or not” or
(3), when the prisoner is asked to plead “ guilty’”’ or “not
guilty ’’, and he takes no notice, whether he is “‘ mute of malice
or by the visitation of God’’. Lastly, if the question of insanity
is raised during the course of the trial, the jury may be asked to
state in their verdict whether they consider the accused “ sane
or insane ’’.
At whatever stage they find a prisoner insane, the judge
makes an order for him to be kept in custody “‘ until His Majesty’s
pleasure shall become known ’’. The usual sequel is an order by
the Home Secretary for the prisoner to be detained in the criminal
asylum at Broadmoor.
The Trial of Lunatics Act, 1883, abolished the old verdict of
acquittal and substituted a special verdict of guilty but insane
at the time of the commission of the offence. This special verdict,
which is a flat contradiction in terms, is now held not to be a
“conviction of the indictment ’’, but tantamount to acquittal
of commission of an actual crime. Hence, after such a finding,
no appeal lies to the Court of Criminal Appeal.
Suicide.—In the eyes of the law suicide is a felony unless
the person is found by a coroner’s jury to have been insane at
the time when he committed the act. By an old Act of Parlia-
ment the goods of a person found guilty of felo de se may be
confiscated by the State, but in practice this is nowadays never
carried out.
Any person who aids and abets another to commit suicide may
be guilty of murder. If two persons agree to commit suicide
together and one fails, the survivor may be guilty of murder. It
a person, in attempting to commit suicide, occasions the death
of another he may be guilty of manslaughter.
Two words of warning by way of conclusion. When a medical
566 MIND AND ITS DISORDERS
witness is called upon to give evidence respecting the mental
condition of an accused person he is allowed a great deal of
latitude and is expected to give his opinion freely; but he must
remember that he is in a Court of Law, not in a lecture theatre,
and he should refrain from wandering into a discourse upon the
disorder from which the accused is suffering. Should he be asked
to express an opinion concerning the prisoner’s responsibility, this
means moral or mental, not legal responsibility. The legal
responsibility is a matter for the jury to decide. And when he
examines a prisoner, he should not discuss the crime itself; he
is there to examine his mentation and it is best to assume the
attitude that he knows nothing of the crime. Of course, if the
prisoner introduces this subject, the conditions are changed.
In any case it is advisable to be provided with writing materials
so that the prisoner’s own words can be taken down in his
presence.
SCHEDULES 507
53 Vict., c. 5, Sched. 2, Form 1.
Petition for an Order for Reception of a
(@ a Justice of
the Peace for Aire
His Honour the Judge
of the County Court of
(4) Full postal ad-
dress, and rank, pro-
Jesston, or occupation.
(c) At
one.
least twenty-
(Zz) A lunatic, oy an
diot, ov a person of un-
sound mind,
(e) Asylum, ov hospi-
tal, or house, @s the case
‘may be.
(J) Lnsert a full de-
scription of the name
and locality of the
asylum, hospital, or
licensed house, or the
Sull name, address, and
desc: tption of the person
who ts to take charge of at
the patient as a single
patient.
(2) Sone day within
14 day's before the date
of the presentation of the
petition.
(h) Here state the con-
nectton or relationship
with the patient.
Private Patient.
gn the datter of......
a person alleged to be of unsound mind.
AIRC E ee ett on One ve cs eee at on See seshineees danas BOOTS cers:
GDCRIDCUICION Of..c-eacc0e- asa. sasaedeseestas tess tse eter aee eemeete
1) Pas eee apres rere eases ss Sanaa’ oanmse ass dal aN neste Meme Beene
SES ERSTE VEO LM ds gam haw ctvse sae nss ses sdevenemadnn den tememeee dee
PPA ASINC) a 02> aadyer odes eas sess reese VOals OL age.
2. I desire to obtain an Order for the Reception
DURANCE SE OC PISGrEP Ee :
Wate C) teers
ee eee eee eeeene
BULLE aU | cee. access EPR SEY OR CE pais abe ba ao
eel aioe SAW CHG. SAR Ger css saccades Sek Sen canae RAE Perey Pr :
SUSU eae aan nesien nd VOL acdsasresea <r exee saattenes ey Arc :
Ameen (Alors wie sast era: sta ceen ceed: Sie eeee fe oeere Ole cue
SAN rere ana actaa cLuee sds ony csus pus S0ae cace oe eens vomap ere os tenerrae
for if the Petitioner is not connected with or
related to the Patient, state as follows :—]
I am not related to or connected with the said...............005
POPSET EHH SHES HHEH HEHEHE EHH HHH HES SSH HHH EHH HEHEHE HHEHR HEHE EHO
The reasons why this Petition is not presented by a
relation or connection are as follows:
568 MIND AND ITS DISORDERS
The circumstances under which this Petition is pre-
sented by me are as follows:
5. I am not related to or connected with either of the
persons signing the certificates which accompany this
petition as (where the petitioner is a man) husband, father,
father-in-law, son, son-in-law, brother, brother-in-law,
partner, or assistant (or where the petitioner is a woman),
wife, mother, mother-in-law, daughter, daughter-in-law,
sister, sister-in-law, partner, or assistant.
6. I undertake to visit the Said......:.1.:.sssmeeenenee eae
BE Ee Ory Ae ea Hoty personally, or by someone specially
appointed by me, at least once in every six months while
under care and treatment under the Order to be made on
this Petition.
7. A Statement of Particulars relating to the said
a ashes oveescuatdswn's@s qoies cpeaenee ence ase heee ssn | penn accompanies
this Petition.
If tt ts the fact, add : 8. The Said.............esessessenee eee
(@) Asylum, or hos- has been received in the (2).......sse0ceecessensestenesseeea aan
pital, or house, as the
case may be.
under an Urgency Order dated the........:2s.maseseeue seen
SOOTHE EH ETE EHH EHH HEHE SEH HEHEHE EEE SEE EEE EEE SHEE EESHEEE SHEE HEE EHEE HEE HEE EHEEEE
The petitioner therefore prays that an Order may be
made in accordance with the foregoing Statement.
(24) Full Christian (Signed) (R) 0.6 0:0 066 6 6/e's o/eieluleisielulo'e’ ets efereta/e is eieteteraiata
and surname.
COC HHEOHHEHHHHEHHEHET EE HHEHH EEE EEE
SCHEDULES 569
53 Vict., c. 5, Sched. 2, Forms 4, 2, 8, and 9g.
Form of Urgency Order for the Reception of a
Private Patient, with Medical Certificate and
Statement accompanying Urgency Order.
3, the undersigned, being a Person Twenty-one years
of age, hereby authorize you to receive as a Patient into
(z) House, or _ hos- your (a)
pital, or asylum, as a
single patient.
(o) Name of patient. (b)
SOT E HE HHHHHHEHEHEEEHEHHEEHEHHEEHEEHEEEHE SER HEHEHE EHS EEEEH HEE EEE EE CHHHED
ee
PME AR AS © 1 (C) ce ses ec owes co ee testasen dees asesnvadscncncaaeses whom I last
idiot, or oo aoc of un-
sound min
SAW CL Us eee woes ey dh ce oh the Woe baler ov oes Cetus ty Secu, > ELT ESRC OONRON NETS eee
(d) Some day within On the (@)..... SPECS a ye BRRO SIS: Day Of, . vicseccacavanvececs Eons a
two days before the date
of the Urder.
3 am not related to or connected with the Person
signing the Certificate which accompanies this Order in
(ec) Husband, wifey any of the ways mentioned in the Margin. (e) Sub-
father, father-in-law,
mother, mother-in-law,
oe PEG ies, joined oy annexed hereto is a Statement of Particulars
brother, brother-in-law,
sister, sister-in-law, part- : 5
ner, oy assistant. Pele RAM EAT CLL OU SAIC ys va ves pases ken ch hessasStnntnamacacgssvessnwemann
(Signed)
[Uf not the husband or Name and Christian Name \
wife, or a relative of the
patient, the person sign- at length = — ca a |
ing to state as briefly es
osstble: 1. Why the
ci tality Mgt stoned by rank, Profession, or Occu- \
the husband or wife, or RNS FRR ofa nisin spin nperinin at aac 8 ae bain) a'ee aoe see ae
a velative of the patient. pation (af any) - ={
2. His or her connection
with the patient, and Fy]] Postal Address - Zp sieRvads cob ths vid. oteh Ve neat
the circumstances under
which he or she signs.)
OOOO eH He EHH EEE HEHEHE HEHEHE HEE EEE EEE
How related to or connected eeeeee eeeeerereeeeeeeereeeeeee eee
with the Patient - -} en ae
Dated this....... Ree Abt: or ERE ey. scans Le eee
(/) ylidueg eset of
=----s= the ----:- asylum,
hospital, 7 resident eeeoee eeeeveave eeeeeeeeeneeeeeeeeeeeeeee
licenseeutthe --. house To Chives ala Wie elole'v s\e'ein slo wis'eiele e'ele'elele
[describing the asylum,
hospital, or house by
situation and name}. Pietra see's gO LIOR E. Ss BORER CPT REE EO STEELE pence
570 MIND AND ITS DISORDERS
Form 2.
Statement of Particulars referred to in the
annexed Petition.
If any Particulars ave not known, the Fact is to be so stated.
[Where the patient is in the Petition described as an idiot, omit the
particulars marked*.]}
The following is a Statement of Particulars relating to the said..................
Name of Patient, with Christian Name at length..............0e,seseeeeepeeee een
Sex and Age - - - - - - ~ sacdcoscegecesneneeee as <eea
*Married, Single, or Widowed - - - scan #'n d.psecocs ee 9:0 eipsie tale eels ee tn
*Rank, Profession, or previous occupation (if)
any) e Ex 2 me = 2 me tee eee eww eee eeeeeeeeseeeeaee
* Religious Persuasion - - - - — nen osecdocueuas eka eae sey enema
’ Residence at or immediately previous to the
dence at of immediately previous tothe\ 1a
*Whether First Attack - - - - ~ cccccetsevcesnncdaualtn tanya
Age on First Attack - - - . ~ ivvccnsocenedag hesieegns agama
When and where previously under Care amd) ..........csccccccceccccessssnsusees
Treatment as a Lunatic, Idiot, or Person
of Unsound Mind - - - ~ @ | sccesesenssuetasanap enema
*Duration of Existing Attack - ~ - m Selvo sd deena cemnt gaeees eRe ean
Supposed Cause - a: - - SPT or
Whether subject to Epilepsy - - - = lecececsec canes siltiee ey eee ee 7a teame
Whether Suicidal - - - - - ~ scncoceseccancticcdtese} i= ieemeean
Whether Dangerous to Others, and in what way..........:....ssscesscsssssuessssee
Whether any near Relative has been afflicted
che; any near Kelative has Deen ailicted| |
Names, Christian Names, and full Postal Ad-) ............:cccccseecescnnsavccvoss
dresses of one or more Relatives of the
Patient - - - - - - SD PTT eC
Name of the Person to whom Notice of Death) ...........cccececsceccecsencccevees
to be sent, and full Postal Address, if not
already given - - - - - - J a co-ceanaieaia ts aaisiemin irda ceteare ae aam
eee eee eee eee ee See SHES SHHEHEEE
tName and full Postal Address of the usual
Medical Attendant of the Patient’ - .
(SIGNED) ccseescvvevewecviccecssersnsensattauneces cose> aa sneeunaanayRaaaEnyEEs
A Similar Statement must also accompany an Urgency Order.
+ Not required in pauper cases or for lunatics wandering at large.
SCHEDULES 571
When the Petitioner or person signing an Urgency Order is Not the
person who signs the Statement, add the following particulars concerning
the person who signs the Statement:
Name, with Christian name at length - -
SSeS e sere eee eeeeseseereresesesere
Rank, profession, or occupation (if any) -
COCO eee rete se eee eee eres Eeeeeeseoes
How related to or otherwise connected with)
the patient 3 i z i 5 By RTs aR eSectd:
BSeVict. oCa5,.S-)31:
When neither Certificate is signed by the usual
Medical Attendant.*
J, the undersigned, hereby state that it is not practicable
to obtain a Certificate from the usual Medical Attendant
a) Name of patient. of (a)
SHOTS HHSHOHSHOSHOSHHHOHSHOEH OHH CES OHH HOH LOE COCR OCHREEHEECO RACES OROCEH CCE CESCES
for the following reasons, viz.:
5) To be signed b {
a Rpt eas asad CSSTQIICO]g (O) an caren case se oocpeusenncs cnccevecsereemes
53 Vict., c. 5, Sched. 2, Form 8.
SE ITLIOMINSALLOLEOL erate ret chca cc tee crocs esau eer estates cc ces eae ies
Pe ME hea oc os (cade rs cass ge case Gennse sbeyuedeesdissonseivetteges
patient.
(5) County, city, or :
borough, ef ee case 1N the (b) cece e reece csccccccccccescceces Si bee inet, pies ewian ateee cet eee
may be.
eae a IT REE MN os oo 0s Sn va fuekeds eons causie¥s siucbesen is cdthsaieens teen
or occupation, tf any. >
an alleged lunatic.
PR MCUIMBUUCCESIONOC Foie. conarogscasnctestsuscuscassssccscnawescedeteers
do hereby certify as follows:
1.I am a person registered under the Medical Act,
1858, and I am in the actual practice of the medical
profession.
* Not required for pauper cases, for lunatics wandering at large or for those
not under proper care and control or being cruelly treated or neglected.
{ Insert name in full.
572 MIND AND ITS DISORDERS
(d) Insert the place of 2. On the
bphination, ohing he At Te Re eee eee eee day Of...02. seen ase cope en
name of the street, with
nmuniber or name of at (a) Coe recon eeececcceeneceeeeececce eoecee Core ore ccrcereceseereeeenesseseess
house, or should there ,
be no number, the Chris- In the (e) evel eV overs, sveiets oleiore (eleuntecsts eerie Of...) eee ai eia aiohelalele ste 6 0 ces nes aemem
tian and surname of
occupier, : :
(6) County, city, or I personally examined the said........ foe woos 00s Dee
orough, as the case .
ay be and came to the conclusion that he is (f)....... sé ds.
(7) A lunatic, an idiot,
or a person of unsound and a proper person to be taken charge of and detained
mind,
under care and treatment.
3. I formed this conclusion on the following grounds,
Vales
(a) Facts indicating Insanity observed by myself at
(g) If the same or the time of examination (g), Viz.: ........s.s0- snes, Ce EP
other facts were obse ved i
previous to the tinte of
the examination, the (°c cess eerseccccvccccscccccssceesscecece © 6 s:wie wie. Sata. elw ale nfatateye ecccvccecces
certifier ts at liberty to
SUOJOCH CHEM TI ASEPAT SE a 0/0 3.4\0n:0\01050\0 5) \oue 6610/0) 4 61s 0 014.8 c)e le blen's eiclciels wba ae ee cccscccce eee erceeseee
ate paragraph.
(4) The names ana (6) Facts communicated by others (h),viz.: ......csceceeeeees
Christian names (t,
known) of informants
to be given with thetr e@eereeeereeeeeee eereeeeeser eee eee eee eee eee eee eene eeeeeeeeee eereereeeeee . . eeereee
“ , 5
addresses and descrip-
LLORES FI PO ia c'0'0, 6.00.0. 0 010.0 08)e-0.5\ 8 68m wi ecsle m vehi ere'ankiniueplare Siptaiare’e seer cee Peewee eee rereeesssene
eeoereeeeeeeeeeeeeseeeeseeeeseseee ieee eee ee ee ee ee ee 2 |
PHCHHCHCOHCEH SS HOCHOHSEH EKA EHEEHOHS OLEH EES OHO SLEHKE CO OSOSCEEEESEEE SESH ESS
(2) If arn wurgercy cer- it is .
ns Ya ER s 3 certify that it is expedient for the welfare of the
t be added here. J
Form Wvea, Bald cavcaccsveds cee Meee nts vote RE RAS ce ...[or for the public
safety, as the case may be] that the Saids............-.sesseeeee
should be forthwith placed under care and treatment.
eee eee eeeeee
ee a] ee eeeeee eee eeee ee | serene
. . . . . . eeee . ereee eres ee
eeeee SHOCHSHHSSOH HOCH SHH SHEHOAOHAHOSSCHOHE SHO HCO ROTH OHE HOCH OSES ESCO DESCELOERHaCSOS EUS SNE
eee eee reene ee POSSCHH HSE SHCHCE HOC ETOCCE OOS OLE COCCC OE DSE DS © SOG 8 0666 6s Us 664 Siale a een
SOT HHHHHHHHEHHEHEHE EHH ET EEE HET H OHHH EEE HEE EES eeeeeee Seer e eee seers eeeeeseeseeee
eeeee COHH HEHEHE HEHEHE HEHEHE HECHT ESC EEO EEE EHS EH OEE EES OEE OEE SEE SELES E LEE OOO
AL ne sSalduine, av: crease csacggeas Coen
(2) Strcke out this appeared to me to be [or not to be] in a fit condition of
clause in case of
brivaté patient whose re- Hodily ‘health tobe removed to°an asylum: hospital, or
moval ts not proposed. ;
licensed house (A).
eeeeree ee ee |
(¢) Insert full posta
address.
SCHEDULES 573
5. I give this certificate having first read the section of
the Act of Parliament printed below.
SD AUC OD CNIS semana tae heen onesn at, day of
One thousand nine hundred and
ey
(SIGNED)... ereereeeeeeceeeeteeeteeeeeeeeeeeeeeeeeees
ee
Extract from Section 317 of the Lunacy Act, 1890.
Any person who makes a wilful misstatement of any material fact in
any medical or other certificate, or in any statement or report of bodily or
mental condition under this Act, shall be guilty of a misdemeanour.
Raewice Ges. Sched. 2, form: 3.
Order for Reception of a Private Patient.
To be made by a Justice appointed under the Lunacy Act, 1890, Judge of
(az) A Justice for:------
specially appointed un-
der the Lunacy Act,
1890 ; ov the. Judge of the
County Court of ------- .
or the Stipendiary
Magistrate for -------.
(6) Address and occi-
tation.
(c) Or an idiot or per-
son of unsound mind.
(d) Name of petitioner.
County Courts, or Stipendiary Magistrate.
J, the undersigned...........ceceeesesceceeeerereneeeeeeeeneneeeeeeees
DPS (ly ee eae ca tees Wan ou Sapo ap tne qncnwannenvosnctans feesecsacetns
Ca MAC eC eC a see Cale Rw De eS 0 © Oem wee Bee sae 50 F'9 SU #10810, 8) 2 o 6/0 M06 Os .0:9'8i8 12 (8008.2 ® SiS Se
PM LEATIC. (Chcsccccces cst encasacnes este ceen accompanied by the
Medical Certificates Of.......scscecvesscececcesseeeeceecssececcessenes
hereto annexed, and upon the undertaking of the said
TD etste hte a. eds pa teac tere rsewesdeenco ners asnee Meens to visit the
574 MIND AND ITS DISORDERS
once at least in every six months while under care and
treatment, under this Order hereby authorize you to
receive the Said 1.5..0...c.sccccecceneese eee ee penne
(e) Asylum, or hos- r :
pital, or house, 07 asa AS A Patient into your (e) 0.006 0.8:6 wie w\nia'is @)9) 6: o's\e.¥e wm aletare a tatetet ner ana re a ievlie tl
single patient. :
And F declare that I have [ov have not] personally
seen 4 the Said snvecce ee ee eee ee ts eas cons omegniee sai eta
before making this Order.
DMATCOT MIS. ce ee tee day of....i03) ee tO...
(GIGNCD) (@)..002...s0000+000000ee-ces sheen
justice for..c:Apee eee appointed
under the above-mentioned Act
[or the Judge of the County
Court Of....seseensesn eee
(/) To be addressed to or a Stipendiary Magistrate].
the medical superinten-
dent of the asylum or
hospttal, or to the resi-
dent licensee of the house To (f) O06 0.910056 0.0 0 60.0056 00 8.0ce weiss selene 636.66 sle/s © atule oiniela Minty a myetals elaine ene
tu which the patient ts
to be placed.
53 Vict, c. 5,18. 7.(4ke
When a Previous Petition has been dismissed.
3, the undersigned, hereby state that a former Petition
(z) Nameof patient. for the Reception of (a).....0.:+-s-..<ssesssanieee eee en
(2) Name of asylum, j
hospital, licensed house into ()
or single charge.
eet OOO OOOH HHO eee Oe eee HHO HHT HEHE HEHEHE THEE EEE EHH HE THETHEE HE EE EEE ETE EES
Was preSemted 0.....056. 020066 ecseceoceessn cee
(c) Justice of the Peace (c)
me ee or Judge of (C)erseteeeseeeceseeececscecseessseseeeceseeesesnessesesnsececeseseseseeeeuss
County Court Of eae roe : ,
or Stipendiary Magis- nthe Month Olea. cesaes creas eee eee 5» Lee , and dismissed.
rate for -.--.- 4
Herewith is a copy (furnished by the Commissioners in
Lunacy) of the Statement sent to them of the reasons for
its dismissal.
(GIGNCO) ..ccse02.0ncscons ence esecendeselenne enter tenement
The Schedules for sending a mentally defective person to an institution
or certified house for mentally defectives or for placing him under guardian-
ship are very similar to those of the Lunacy Acts. When required, the forms
can be obtained from Shaw and Sons, Fetter Lane, London, E.C. 4.
.
APPENDIX A.
METHODS OF STAINING THE NERVOUS SYSTEM.
For all ordinary purposes the following methods of making
microscopic preparations of the nervous system will be found
sufficient.
Pieces of tissue requiring examination should be not more than
% to I centimetre in thickness and should be hardened as a rule
in a 10 per cent. solution of formalin, formalin being a 40 per
cent. solution of formaldehyde. The specimens are ready for
further treatment in about ten days.
To prepare them for the microtome they should be washed for
twelve hours in running water, placed in methylated spirit for
twenty-four hours, then in absolute alcohol and ether (equal
parts) for twenty-four hours. They are then ready for em-
bedding in photoxylin, a substance closely related to celloidin.
They should first be placed in thin photoxylin solution (1) and
then transferred to a thick solution (2) of syrupy consistence:
iijmehotoxyln’ ... ve se mee ail
Absolute alcohol... by cee taxlts
Ether om a a San Se atk
(2) Photoxylin.. ae Ye eho Iv
Absolute alcohol ar re me Ae
Pier .s. oy nee te al
They are mounted on pieces of wood about # inch cubical.
The piece of tissue is taken on a section lifter out of the second
photoxylin jar and placed on a piece of wood, with plenty of the
photoxylin solution round it. There it remains for a variable
time, about a quarter of an hour in moderately warm weather,
until the photoxylin becomes of the consistence of a firm jelly.
The specimen is labelled by writing in pencil on the wood and
the whole thing then dropped into a jar of methylated spirit to
await section.
D772
576 MIND AND ITS DISORDERS
Any microtome may be used. The author is accustomed to
use Schanze’s instrument.
As the sections are cut they are transferred to a pot of methy-
lated spirit.
Nissvc’s METHOD OF STAINING NERVE-CELLS.
The sections are placed on the surface of some Griibler’s.
solution of polychromatic methylene-blue in a watch-glass, which
is then warmed over a flame until steam appears. They are
removed by means of a needle and placed in a basin of water,
washed and transferred on a section lifter to methylated spirit,
which dissolves out much of the methylene-blue. They are
then passed through absolute alcohol, where they remain until
differentiation is complete, into aniline oil which stops the
process. Some pathologists, instead of using the absolute
alcohol and aniline oil. separately, leave the sections for some
hours in a mixture of the two (equal parts).
The sections are then passed through oil of origanum into
benzene, in which they may remain for any length of time. They
are finally mounted in colophonium resin dissolved in benzene,
which may be lighted and partly burnt off before applying the
cover-glass.
Cox’s METHOD OF OBTAINING A SILHOUETTE OF NERVE-CELLS
AND THEIR PROCESSES.
At the autopsy pieces of fresh tissue are washed free from
blood and placed in the following:
5 per cent. solution of perchloride of
mercury me 20 parts
5 per cent. solution of alone potassium
chromate a es Es . toe
Distilled water .. 40 ,,
5 per cent. solution of potasciuen bi-
chromate ~ a ae .. 200s
The bichromate solution should be added last.
The pieces are transferred next day to fresh solution and
are ready for cutting in three months. They should not be cut
too thin.
The nerve-cells and their processes appear black against a
white background.
METHODS OF STAINING 577
STAINS FOR TRACT DEGENERATION.
If the tract degeneration is recent, one to six weeks old,
advantage is taken of the fact that, while the phosphorized
fat of medullary sheaths does not stain with osmic acid, the
dephosphorized fat of degenerating medullary sheaths does.
The pieces of nerve tissue to be examined are best fixed in
Miiller’s fluid, which consists of:
Potassium bichromate .. sf Pa. 62) parts
Sodium sulphate .. a an emeels Done
Distilled water .. ne fs -. 100 parts;
but it does not matter if they have been in formalin first.
They are placed for about a fortnight in Marchi’s fluid:
I per cent. solution of osmic acid .. 1 part
2 per cent. solution of potassium bi-
chromate .. ats Pe 2 parts:
washed in running water for twenty-four hours and hardened in
alcohol. They are then mounted in photoxylin, as described
‘above, and cut. The sections should not be too thin. The
degenerated myelin sheaths appear black.
If the tract degeneration is of long standing, the following
method of staining the myelin sheaths may be employed (Weigert-
Pal).
The sections are cut and lie in methylated spirit. They should
be treated separately.
They are first stained for twenty-four hours in Kultschitzky’s
hematoxylin:
Hematoxylin .. oe ie .. 2 grammes
Absolute alcohol ey .. Enough to dissolve
Acetic acid (2 per cent. solution) .. I00C.c.
This is at its best when it is some months old.
The sections are washed in distilled water and placed in
Miiller’s fluid for two minutes, washed again and placed in a
solution of potassium permanganate (75 grammes to I pint)
until the grey matter is of a yellow tint (usually about one
minute). They are again washed and then transferred to Pal’s
solution:
Pure oxalic acid .. ay ae Peeeuleo lame
Potassium sulphite 1: : igh
Distilled water .. - + eas 200.C.C;
SY;
578 MIND AND ITS DISORDERS
If the differentiation is not complete, the sections should be
washed and the whoje process repeated from the potassium
permanganate.
The sections are now placed in a strong solution of lithium
carbonate for a quarter of an hour and once more washed. |
They may be counterstained with picrocarmine.
Dehydrate in
Xylol re eae 3 parts
Absolute phenol .. Di ig i! opare
and mount in Canada balsam.
The degenerated tracts appear pale against a blue back-
ground, the undegenerated myelin sheaths being stained blue.
STAIN FOR AXIS CYLINDERS.
There is at present no very satisfactory stain for axis cylinders,
but the following method (Freud’s) may be tried:
Fresh pieces are hardened, preferably in the dark, in Miller’s
fluid, washed, further hardened in rectified spirit, embedded in
photoxylin and cut. The sections are steeped for about four
hours in
Gold chloride solution (1 per cent.)
Alcohol (95 per cent.) \ equal parts.
They are then washed and placed for three minutes in
Saturated solution of sodium hydrate .. I part
Distilled water... ae ff o+ ld tes
They are again rinsed and steeped for about ten minutes in a
Io per cent. solution of potassium iodide. At this stage they
assume a reddish-violet colour. They are now washed, cleared
in methylated spirit, absolute alcohol and xylol and mounted in
Canada balsam.
Metal instruments must be avoided and glass ones ssed
instead.
WEIGERT’S STAIN FOR NEUROGLIA.
The pieces are hardened and mordanted in the following fluid
for ten days:
Chrome alum sy 7 a .. 24 grammes
Copper acetate .. cag 3 es ny
Acetic acid is fp te ae op ve
Formalin .. mae ue <' ve Ate
Distilled water ,. oo $2 ho 90
METHODS OF STAINING 579
Boil the chrome alum in 80 c.c. of water. Turn out the Bunsen
and add the acetic acid, then stir in the copper acetate while the
mixture is still hot. Filter when cold, then add the formalin and
the rest of the water.
It does not matter if the tissue has previously been hardened
in formalin. Sections are made by the photoxylin method.
From spirit the sections are transferred to water, then to a
I in 300 solution of potassium permanganate for ten minutes.
They are washed and placed in the following reducing solution:
Chromogen i a Me .. 5 grammes
Formic acid es Ay - SE HONE
Io per cent. solution of sodium sulphite 10 c.c.
Distilled water .. i ire Le ee Nedes
The sodium sulphite is added immediately before using the
solution.
When the brown sections have been decolorized they are
twice thoroughly rinsed and placed in a 5 per cent. aqueous
solution of chromogen for a few minutes.
They may then be counterstained, preferably on the slide,
with
Saturated solution of picric acid ee LO, G.Gr
I per cent. solution of soda-carmine .. 2 C.C.
Absolute alcohol .. ~ me ae, Aa ees
The section is now blotted and a saturated solution of methyl
violet in rectified spirit dropped on it. This solution must be
prepared with hot alcohol and be filtered after cooling. The
section stains almost instantaneously.
The superfluous methyl violet is blotted up and a saturated
solution of iodine in a 5 per cent. solution of potassium todide
dropped on the specimen and immediately poured off. The
specimen is then thoroughly washed in aniline-xylol (equal
parts), then in pure xylol and finally mounted in Canada balsam.
APPENDIX B.
EXAMINATION OF THE CEREBRO-SPINAL FLUID.
AN examination of the cerebro-spinal fluid is sometimes of
assistance in the diagnosis of disease. In the department of
medicine which forms the subject of this book such an examina-
tion is especially useful as an aid to diagnosis in doubtful cases
of general paralysis.
Lumbar Puneture.—A specimen of the fluid may be obtained
during life and without injury to the nervous system by means of
a hollow needle passed into the spinal canal, preferably between
the fourth and fifth lumbar spines. This may be done while
the patient lies in bed on his side, but it is much better if he sits
on a low stool, stoops forward and dangles his arms between his
knees, the finger-tips resting on the floor. This position tends
to separate the lumbar spines from one another.
The requisite apparatus consists of a test-tube, a hollow needle
made of platinum or iridium so that it will not snap and may
be boiled without rusting, a stilette of the same metal and an
all-glass syringe or a suitable piece of metal to fit the end of
the needle and serve as a handle. These should all have been
sterilized by heat and the patient’s skin over the fourth and fifth
lumbar spines cleaned and painted with iodine liniment.
Now a straight line drawn across the back at the level of the
highest point of the iliac crest passes over the fourth lumbar
spine. The needle should therefore be entered immediately
below this.
The operator places his left forefinger over the fourth lumbar
spine to serve as a guide and enters the needle in the middle
line in the space immediately below. The needle is pushed
horizontally forward for a distance of 3} inches (in an adult).
Should the operator strike bone, the needle must be slightly
withdrawn and pushed in a little higher or lower, as the case
may be. When the handle or syringe is removed the fluid
drops from the end of the needle. If this does not happen the
lumen of the needle should be cleared by means of the stilette.
The first few drops are allowed to escape since they are liable
to be contaminated with blood; then about 5 to 8 c.c. are collected
580
THE CEREBRO-SPINAL FLUID 581
in the test-tube. This is closed with a piece of sterilized wool and
the wound sealed with collodion.
The intraspinal pressure can be judged sufficiently for practical
purposes by observing the force of the stream from the puncture
needle. If the fluid runs with a strong stream more or less like
the flow of urine in micturition, the pressure is high; if it falls
in a continuous stream almost vertically from the end of the
needle the pressure is moderate; if it falls in an interrupted
stream or in drops, the pressure is low. For more accurate
investigations a Landon manometer may be used. Readings
above 12 mm. should be regarded with suspicion; those above
20 mm. are undoubtedly pathological. The pressure is increased
especially in general paralysis, meningitis, cerebral and spinal
tumours and hydrocephalus.
Preparation of Specimens for Cytological Examination.—The
most practical method is that of Fuchs and Rosenthal, who have
invented a slide somewhat similar to the Thoma-Zeiss slide but
with larger divisions and twice the depth.* Unna’s polychrome
methylene-blue is drawn up to the 0:5 mark of a white corpuscle
pipette and cerebro-spinal fluid up to the rz mark. Fluid and
stain are shaken together for four or five minutes. The first two
or three drops from the pipette are rejected and the mixture is
then allowed to flow over the slide and to settle for at least five
minutes. The quantity of fluid should be insufficient to flow
over into the moat. The rulings are 4 mm. square and the depth
of the fluid is 0-2 mm. The number of cells is counted in 16 sets
of 16 squares and the result multiplied by 21 and divided by 64.
This gives the number of cells per c.mm. A differential count
may also be made.
Henderson gives the following standards as satisfactory:
Less than 5 cells per c.mm. - .. negative
From 5 to 10 mf ae zt .. doubtful
pbove 10. = gh a .. pleocytosis
Alzheimer’s method is as follows:
Absolute alcohol is added to the fluid in the proportion of
one to two, and the whole well shaken to ensure thorough mixture.
This coagulates the albuminous constituents.
The mixture is placed in the electric centrifuge for one hour.
This drives to the bottom of the test-tube the particles of coagu-
* The slide is made in solid glass, so as to do away with any error
resulting from contraction of Canada balsam, by Messrs. Hawksley and
Son, 357, Oxford Street, London, Wt:
582 MIND AND ITS DISORDERS
lated albumin with any cellular constituents and welds them
into a little solid mass.
The supernatant fluid is poured off and the mass is hardened
by treating it with absolute alcohol for one hour.
It is now treated with alcohol and ether (equal parts), then
with ether (one hour each), loosened from the bottom of the
test-tube with a fine platinum needle and gently shaken into ©
thin photoxylin in which it remains for twelve hours or more.
It is then transferred to thick photoxylin and mounted on a block
of wood as described in Appendix A.
Sections are made of a thickness of 14p and stained for about
six minutes in the following solution (Pappenheim’s pyronin
methyl green) in the incubator:
Methyl green oe se ~ *.- “Or Seeante
Pyronin =. Ay a .. "O25 aaee
Alcohol (96 per cent. | etc s/ 2 see
Carbolic acid (5 per cent.) 45 .. YOOuEe
The sections are immediately transferred to a basin of cold
water to remove superfluous stain and placed in absolute alcohol
until the colour ceases to come away.
Lastly they are cleared in xylol or oil of cloves and mounted
in Canada balsam.
So far as I am aware, there is no reason why pyronin-methyl
green should not be used in the Fuchs and Rosenthal method.
It would give a differential stain, but I have not tried it.
Cytological Examination.—The microscopical appearance of
a specimen prepared in the above manner is shown in Fig. 72.
Nuclei are stained blue and protoplasm pink.
Lymphocytes.—These are nearly all nucleus with a “ clock-
face ’’ arrangement of chromophilic granules.
Endothelial Cells—The nucleus is “ horse-shoe’”’ shaped or
oval and eccentric in position. There are very few or no
chromophile granules. The nucleus does not stain quite so
deeply as that of lymphocytes. They are sometimes phago-
cytic, as seen in the cell marked “ phagocyte ”’ in Fig. 72.
Plasma Cells.—The nucleus is eccentric in position and has a
well-marked “ clock-face ’’ arrangement of chromophile granules.
The protoplasm stains more deeply at the periphery than | near
the nucleus.
Polymorphonuclear Leucocytes.—The appearance of these is too
well known to require description. The nucleus is of charac-
THE CEREBRO-SPINAL FLUID 583
teristic shape and the protoplasm is not stained by the above
method.
In normal fluid one may expect to find five to fifteen cells in a
hundred fields, lymphocytes and endothelial cells only.
In general paralysis all the above forms are common and
plasma cells rarely occur in any other disease. In Alzheimer
sections there may be 200 to 1,000 or more cells in roo fields,
but the characteristic feature is the high percentage of lympho-
cytes (over 60 per cent. in 80 per cent. of cases and over 70
per cent. in 70 per cent. of cases). The cell-count is for some
unknown reason much higher when the fluid is obtained post
mortem.
Globulin Reaction.—The Nonne-Apelt is by far the most
satisfactory test. Equal parts of cerebro-spinal fluid and a
saturated solution of ammonium sulphate are shaken together
in a test-tube. If a cloudiness appears within three minutes
the quantity of globulin is excessive and a positive reaction of
this nature is a strong argument in favour of the diagnosis of
general paralysis.
Other tests for globulin are the formation of a nitric acid
ring, as in testing urine for albuminuria; formation of a cloudy
ring with a saturated solution of ammonium sulphate (Ross-
Jones) and the formation of a flocculent precipitate on boiling
2 c.c. of cerebro-spinal fluid with 5 c.c. of a Io per cent.
solution of butyric acid in physiological salt solution and then
boiling this with a I c.c. of normal sodium hydrate solution
(Noguchi).
The Gold-Sol Test for General Paralysis.—This is a kind of
quantitative test for globulin, which is based upon the observa-
tions that (1) protein solutions will precipitate colloidal gold in
the absence of an electrolyte (such as sodium chloride), (2) an
electrolyte will in certain concentrations precipitate colloidal
gold and (3) there is a minimal precipitation of proteins and
colloidal gold when in the same mixture a 0-4 per cent. solution
of sodium chloride is used.
Preparation of the Colloidal Gold Solution.—All the glass
apparatus (including thermometers) used must be rendered
chemically clean by boiling in bichromate cleaner for half an hour,
washed in tap water and ultimately in water triply distilled in
an apparatus with no rubber connections. All solutions used
must be in such triply distilled water.
Heat over a Bunsen burner 1,000 c.c. of this triply distilled
water in a beaker, with a thermometer.
584 MIND AND ITS DISORDERS
At 60° C. add 10 c.c. of a I per cent. solution of gold chloride
crystals and 7 c.c. of a 2 per cent. solution of pure K,CO,.
At 80° C., while stirring, add 10 drops of a 1 per cent. solution
of pure oxalic acid.
At go° C. remove the burner and, while stirring, add 5 c.c. of a
1 in 40 solution of pure formaldehyde, 7.e., till a pinkish tinge
begins to appear.
Subsequently the resulting fluid becomes orange to salmon-red. —
It should be perfectly clear and neutral in reaction, giving a
brownish-red coloration with a 1 per cent. solution of alizarin-red
in 50 per cent. alcohol. If it is not neutral it should be rendered
so by a drop or two of 1 in 50 NaHO, or I in 50 HCl (by weight),
as the case may be. |
The Test.—Arrange 11 test-tubes (chemically clean like all the
other apparatus) in a row. Put into the first tube 1°8 c.c. and
into each of the others 1 c.c. of fresh sterile NaCl solution (0-4 per
cents):
Add to the first tube 0-2 c.c. of the cerebro-spinal fluid to be
examined and mix (of course there should be no blood in it).
Transfer 1 c.c. from the first to the second tube and mix. Transfer
t c.c. from the second to the third tube and mix; and so on to the
tenth. The eleventh is the control and contains no cerebro-
spinal fluid. Add to each of the eleven tubes 5 c.c. of the colloidal
gold solution ; mix and set aside for the night.
The Reaction.—The readings are recorded next day according
to the following scheme:
5=complete decolorization (like water)
4=pale blue
3=blue
2=violet or purple
1=bluish-red
o==no change
Normal cerebro-spinal fluid produces no change or perhaps a
No. 1 change in the first tube only.
In general paralysis a typical reaction is at least 5555422110.
An undoubted case may give 5555554211.
A somewhat similar result occurs in disseminated sclerosis,
but the decolorization and precipitation in the earlier tubes
are not quite so complete.
In tabes decolorization occurs in the early middle (“ luetic ’’)
zone, for example—4445543100.
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‘ie
THE CEREBRO-SPINAL FLUID 585
This difference between the general paralytic and_tabetic
reactions is helpful in those cases in which a diagnosis has to be
made between general paralysis and tabes plus a functional
mental disorder.
In cerebral arteriopathy from syphilitic endarteritis the reaction
is rather like that of general paralysis but much weaker, such as
4331100000.
The test is primarily intended for general paralysis; for other
conditions it is rather unreliable. A sound summary of the
situation is given by J. Cruickshank in vol. i., part i, of the
Journal of Experimental Pathology (1920).
Wassermann Reaction.—The cerebro-spinal fluid may also
be tested for the Wassermann reaction. A positive reaction
probably means general paralysis, but opinions are still divided
on this point; it must certainly be regarded as very strong
evidence in favour of the diagnosis of general paralysis in those
cases in which the test is made for the purpose of deciding whether
the patient is or is not suffering from general paralysis.
The test is exceedingly technical and should always be left to
a pathologist who is familiar with the technique. For details
the reader is referred to ‘‘ The? Wassermann Reaction’ by
J. W. Marchildon (Kimpton).
INDEX
A
ABDOMINAL sensations, 128
Abnormalities of action, 152
general, 218
Abstinence symptoms (cocaine), 380 |
» x (morphia), 377
Acceleration of thought, 141
Achromatoplasm, 5
Acne vulgaris, 528
Acrophobia, 239
Action, disorders of, 152
», warieties of, 65
Actions of imbeciles, 497
Activity, pressure of, 155
Acute confusional insanity, 388
», delirious mania, 292, 295
Addison’s disease, 428
Adenoma sebaceum, 530
Adrenalemia, 240, 490
‘Esthetic sentiments, 104
Affection, 54
Agitated melancholia, 273
Agnostic apraxia, 152, 392
a perseveration, 126
Agoraphobia, 239, 256
Alcoholic dementia, 416
insanities, 399
paranoia, 415
ye seudoparesis, 411
Aicohniers B72 z :
Alzheimer’s disease, 481
- staining, 581
Amaurotic family idiots, 501
Amentia, 492
Amnesia, I41
Amylene hydrate, 278, 545
Anesthesia, systematized, 126
Anal erotism, 183
Analgesia, 118, 290, 299, 321, 390
Anergic stupor, 295
Anomalies of the eyes, 216
Anterograde amnesia, I41
Antics, 327
Anxietas presenilis, 275
Anxiety hysteria, 238
A neurosis, 219
Aphonia, hysterical, 238
Apoplectiform attacks, 434
Apraxia, 152, 159, 482
a)
39
| Aprosexia, 163
| Arteriopathic dementia, 473
| Articular space-perception, 40
| Association centres, 10
ns of ideas, 47
Asylum, dysentery, 524
» plthisigszs
Atavistic abnormalities, 212
Atropine poisoning, 386
Attention, disorders of, 163
laws of, 86
eo varieties of, 88
| Auditory sensation, 24
| 5 space-perception, 41
Automatic action, 80
ss obedience, 158, 324, 336
Automatism, epileptic, 361
Axons, 5, 6
Aztec idiots, 502
+”)
B
Babinski’s conception of hysteria,
230
| Bath (douche and needle), 545
», prolonged, 545
| Bed treatment, 276, 293, 540
| Belief, 106
Belladonna poisoning, 386
Bestiality, 197
Binet-Simon tests, 505
Binocular vision, 33
| Blind-spot, 22
| Blood-pressure, 208, 320
Blushing, 256
Borderland cases, 308
C
_ Changed personalities, 172
Chloralamide, 547
Chloral delirium tremens, 407
,- sHydrate, S47
| Chloralism, 388
Chorea, 484
,, Huntington’s, 485
_ Chromatolysis, 410, 460
Chromatoplasm, 5
Chronic alcoholism, 372
cortical atrophy, 473
»”»
586
INDEX
Chronic hallucinatory insanity, 413
3) «6MaATa, 292
», sulphonal poisoning, 384
Civilization and insanity, 206
Civil responsibilities of the insane,
560
Clang-tint, 25
Claustrophobia, 239, 256
Cocaine paranoia, 382
Cocainism, 381
Cognition, 49
Cold, hallucinations of, 133
», spots, 26
Collaterals, 7
Colonies, epileptic, 371
Colour vision, 65
Combined insanities, 515
Commission, Lunacy, 550
Communicated insanity, 314
Complementary colours, 33
Complexes, 53, 180
Complex hallucinations of hearing,
130
a = of vision,
131
Comprehensiveness of mental dis-
order, 174
Conception, 43
Conduct, 65
fs. disorders of, 152
Cones of retina, 21
Confusion, epileptic, 360
Confusional insanity, 388
Congenital deformities, 211
Contraband of lunacy, 540
Contracts with the insane, 560
Contracture, 94
¥ hysterical, 237
Contrasts, gustatory, 27
Hi olfactory, 27
A simultaneous and
cessive (colour), 23
Convalescence, 549
Conversion hysteria, 233
Convulsions in epilepsy, 355
in general paralysis, 446
F in hysteria, 235
Coprolalia, 337
Coprophobia, 257
Cortico-rubro-spinal system, 61
Cox’s stain, 576
Cranial anomalies, 211
Cranks, 307
Cretinism, 420
Criminal responsibility, 561
Cry, epileptic, 356
Crystallophobia, 256
Cunnilingus, 196
Cutaneous affections, 218, 264
anesthesia, 118
analgesia, 118
suc-
a?
a”
587
Cutaneous sensation, 25
ne Space-perception, 39
re stigmata, 218
Cytological examination, 582
D
Deformities of head, pinna, etc., 211
Degenerative stigmata, 216
Delinquency, 499
‘‘ Délire chronique,” 346
Delirium, epileptic, 360
s hysterical, 241
Pe tremens, 402
4 rf chloral, 383, 407
Delusions, 165
SS in general paralysis, 439
5 in melancholia, 272
Dementia, alcoholic, 416
Ps arteriopathic, 413
ie epileptic, 362
maniacal-depressive in-
sanity, 299
= paralytica, 431
5 paranoides, 311, 338
za precox.3i7
Pi senile, 475
Af syphilitic, 473
Dendrons, 5
Depressio apathetica, 275
Depression, epileptic, 359
Deprivation of senses, 494
Determinism, 79, 85, 179
Dial, 456
Dialacetin, 369
Digestive disturbances,
284
Dilatation of stomach, 239
Dipsomania, 258
Disappearances, mysterious, 361
Disorders of association of ideas,
140-1
m of conduct, 152, 324
x of emotion, 148
* of instinct, 155
- of memory, 141
. of movement, 235
~ of perception, 124
ie of sensation, 188, 233
. of sentiment, 170
i of speech, 158
a of vision, 120
F of volition, 152
Disorientation, 360, 391, 402, 406,
44
Dissociation, 230
Distance, estimation of, 39
Distractibility, 226
Douche bath, 545
Dreams, 99, 189, 270
Drug habits, 371
Dysentery in asylums, 524
264, 280,
588 MIND
E
Ears, deformities of, 213
Eccentrics, 307
Echolalia, 159, 325
Echopraxia, 158, 324, 325
Eclampsic idiocy, 502
Ecmnesia, 241
Edridge-Green’s colour theory, 21
Ego, 112
,, Changed, 172
Ego-instincts, 75
Egocentric paranoia, 308
Emotional reaction defect, 150
Ue, excess, 148
Emotions, 57-8
repressed, 63
Encephalitis, chronic, 504
os lethargica, 468
End-bulbs, 25
Endocrines, 419
Endothelial cells, 582
Ependymal granulation, 465, 479
Epicritic sensation, 16
Epidemic encephalitis, 468
Epigastric sensation, 128
Epilepsy, 349
By minor, 357
Epileptic fits in general paralysis,
434
» aure, 354
7 automatism, 361
- character, 351
As confusion, 360
2 convulsion, 355
=: delirium, 360
aS equivalents, 358
Ae idiocy, 503
a insanity, 350
state, 358, 434
Epiloia, 504
Ereutophobia, 256
Ergograph, 93
Ergophobia, 227
Erroneous instincts, 157
Pr judgments, 165
y localization, 123
Erythrasma, 528
Escape, 558
Ether inebriety, 386
Exhaustion, 92, 290
ye insanity, 388
physical basis of, 60
Exophthalmic goitre, 246
Eyes, anomalies of, 216
F
Facilitation, 8
Faddists, 307
Faradism, 281
AND ITS DISORDERS
Fatigue, 92
Fear in exophthalmic goitre, 246
Fears, irrepressible, 254
Febrile attacks in general paralysis,
435
Fechner’s law, 19
Feeble-minded, 557
Feigned insanity, 518
Fellatio, 196
Felo-de-se, 565
Fetichism, 196 —
Fits, alcoholic, 411
,, epileptic, 355
,, general paralytic, 434
,, hystero-epileptic, 236
Fixation hysteria, 238
Flexibilitas cerea, 324
Flight of ideas, 141
Focal symptoms, 464
Folie a deux, 314
,, de toucher, 158
Food and feeding, 542
Forehead wrinkling in dementia
precox, 322
in melancholia,
266
a”) a2
Forgetting, 50
Free association, 188
Freud’s psychology, 176
Fright, 203
Frontal lesions, 464
‘“ Funny-bone ”’ anesthesia, 438
Furor, epileptic, 360
Gastric dilatation, 209
Gemmules, 6
General paralysis, 431
a ae juvenile, 447
a treatment, 539
Genetous idiocy, 501
Genital sense, 121
», hallucinations of, 134
Glia cells, 458-9
Globulin reaction, 583
Globus hystericus, 128, 235
““Glove’”’ anesthesia, 234
Glycosuria, 491
Goitre, exophthalmic, 246
Gold-Sol test, 580
Gout, 491
Gustatisms, 129
Gustatory contrasts, 27
oe sensations, 26
1s!
Habit, 80
Hematoma auris, 214
Hematoporphyrinuria, 278, 354
Hair in dementia pracox, 320
», overgrowth of, 218, 529
INDEX 589
Hallucinations, 27
def in delirium tremens, I
135, 401 Ideation, 30
Pi in exhaustion, 92, difficulty of, 139
390 physical basis of, 30
os of cold, 133 Ideational inertia, agnostic, 125-6,
+ of pain, 133 392
aA olfactory, 132 of », apraxia, 153,161,
4 psychology of, 139 392, 475
Fe sexual, 134 4 type, 44, 139
hs tactile, 133 Ideomotor apraxia, 153
A visceral, 134 Idiocy, 492
warmth, 133
Hands, ‘ deformities “of, 216, 317,
319
Handshake in dementia precox,
329
Bs in mania, 285
in melancholia, 267
Haschisch poisoning, 385
Head injury, 467
Hearing, 24, 121
¥ defect of, 121, 438, 473
Hebephrenia, 332
Hemianesthesia, hysterical, 233
Hemianopia, hysterical, 234
Hemiplegia, hysterical, 237, 564
Herd, 75-6
Heredity, 199
Homicidal impulse, 258
-Homosexuality, 192
Hormonal, 281
Hospitals, registered, 551
Houses, licensed, 550
Huntington’s chorea, 485
Hydrocephaly, 502
Hydrotherapy, 545
Hyperesthesia, 122, 225, 235, 287
Hypermnesia, 146, 292, 497
Hyperprosexia, 164
Hyperpyrexia in general paralysis,
452
Hypertrichosis, 529
Hypertrophic idiocy, 502
Hypnosis, 101
Hypnotics, 545
Hypochondriacal melancholia, 274
paranoia, 316
Hypochondriasis, 310
Hypothyroidism, treatment by, 282
Hypotonia in anergic stupor, 296
Hysteria, 230
4 anxiety, 238
* cataleptic, 237
" conversion, 233
hp fixation, 238
Hysterical fits, 236
ie insanity, 241
4, monoplegia, 237
An paraplegia, 237
Hystero-epilepsy, 236
Illegitimacy, 492
Illusions, 127
Fe of memory, 147
fe of recognition, 147
- psychology of, 139
Imagination, 5
Imbecility, 496
“ moral, 499
Imperception, 124, 390, 402, 406,
412, 474, 481, 484
+ physical basis of, 126
Impulses, irrepressible, 257
Impulsive action, 71
Inaction, 80
Incidence of insanity, 173, 194
Incoherence, 159, 289
Indian hemp, 385
Inebriation, 398
Inertia of attention, 87, 125, 161,
163, 392, 475
,, Of emotion, 59
», Of ideation, 124, 153
Infantile psychosexual trends, 183
Inhibition, 180
Injury to head, 467
Inquisition as to lunacy, 556
Insane and the law, 550
““ Insane fingers,” 529
Insight, 169
Instinctive attention, 88
diminution of,
164
“ language, 68, 109
Instincts, 65
x classification of, 72
disorders of, 155, 262, 324,
a? a?
440
Intellectual fatigue, 94
an sentiments, 106
Interactionist school, 4
Intercranial pressure, 463
Interest, 91, 164
Intermittent insanity, 261, 302
Interpretation of dreams, 189
Intoxication, 388
Intrapsychic ataxia, 332
Intraspinal pressure, 581
Inversion, sexual, 192
Isopral, 547
299
Irrepressible fears and thoughts, 254
” impulses, 257
J
Janet’s conception of hysteria, 230
doo ESE 2 34.
Jaw deformities, 216
Joffroy’s sign, 439
Judgments, 52
Judicial inquisition as to lunacy, 556
Justice’s order, 6
K
Katatonia, 334
Katatoniac stupor, 335
Kinesthetic equivalent, 30
Kinetoplasm, 5
Korssakow’s syndrome, 408
Krause’s end-bulbs, 25
Kultschitzky’s hematoxylin, 577
L
Language, 109
. and the unconscious, III
ys instinctive, 68, 109
Law of regression, 143
», Of relativity, 13
», Weber-Fechner, 19
Lead encephalopathy, 387
Leave of absence, 558
Legal aspects of insanity, 550
», Capacities of the insane, 559
», responsibilities of the insane,
560, 561
Lesbian love, 192
Letters, 548
Leucoderma, 529
Licensed houses, 550
Lichen planus, 533
Local signs, 31, 38
Locke’s experiment, 26
Lumbar puncture, 580
Luminal-sodium, 369
Lunacy Commission, 550
Lymphocytes, 582
M
Malarial treatment for
paralysis, 451
Malingering, 518
Mania, 283
Mania a potu, 399
Maniacal-depressive psychosis, 260
Maniacal form of general paralysis,
general
445
# handshake, 285
Mannerisms, 158, 327
Marchi’s stain, 577
Marriage, advisability of, 303
ey incidence of insanity, 202
MIND AND ITS DISORDERS
Marriage, nullity of, 560
Masochism, 194
Massage, 281
Mast-cells, 458
Masturbation, 191, 209, 225, 547.
Mattoids, 307
Mechanical restraint, 542
Meco-narceine, 380
Medical certificate, 533
Medicines, 545
Medinal, 546
Meissner’ S$ corpuscles, 25
Melancholia, 263
senile, 274-5
Melancholiac handshake, 267
as wrinkling, 266
Memory, 50
i apparatus, 48
7 disorders of, 141
iy illusions of, 147
. image, 50
Meningitis, aoe
type, 44
Mental deficiency, 492
ns ” Act, 557
», exhaustion, 388
», hospitals, 551
» Yeflexes, 102
Mentation, unity of, 117
Microcephalic idiocy, 502
Mind, 9
Monakow’s bundle, 63
Mongolian idiocy, 501
Monoplegia, hysterical, 237
Moods, 60
Moral imbecility, 499
Moral sentiments, 106
Moria, 465
Morons, 505
Morphia, 547
Morphinism, 376
Motor apraxia, 153
», ceactions, Si74
» signs of mania, 285
,, Of melancholia, 266
Muscular fatigue, 93
Mutism, hysterical, 238
Mysophobia, 255
Myxcedema, 419
N
Narcolepsy, 362
Necrophilia, 197
Negativism, 157, 323, 325, 337
Neologism, 133, 345
Neurasthenia, 224
Neurin, 8
Neuroglia in general paralysis, 458
Neurokyme, 8
Neuron theory, 7
Neurosis, 219
INDEX
Nissl stain, 576
»,» bodies; 5
Noguchi test, 583
Noises, 24
Nonne-Apelt test, 583
Noopsyche, 331
Now-ness, feeling of, 43
Nullity of marriage, 560
O
Obedience, automatic,
330
Obsessional neurosis, 252
Occasionalism, 4
Occupation, 276, 542
ie delirium, 403
Ocular signs of general paralysis,
435-6
Olfactisms, 129
Olfactory sensations, 27
Opisthotonos, 236
Opium, 547
» habit, 376
Optic neuritis, 464
Order, after inquisition, 556
,, by acommissioner, 556
», forms, 567-574
», Justice’s, 554
», Reception, summary, 555
» Urgency, 555
Organic insanities, 430
Osmic acid stain, 577
Oxy-di-morphine, 377
158, 324,
Er
Pachymeningitis haemorrhagica in-
terna, 455
Pack, wet, 545
Pain, hallucinations of, 133
Pain-spots, 25
Palate, deformities of, 215
Pancreas, 429
Pappenheim’s stain, 582
Paresthesia, 123
Paraldehyde, 278, 545
Paraldehydism, 384
Paralysis agitans, 486
Paralysis of voluntary movement,
154
Paramnesia, 147, 406, 480
Paranoia, 304
i alcoholic, 415
a cocaine, 382
Paranoid dementia, 311, 338
Paraphrenia, 311, 343
Paraplegia, hysterical, 237
Parathyroid, 429
Parkinsonian syndrome, 470
Passions, 60 -
Pauper lunatics, 552, 555
591
Pederasty, 192
Pellagra, 530
Perception, 30
v disorders of, 124
» of space, 32
» of time, 42
- physical basis of, 31
Periodic insanity, 262
Perseveration, 125-6, 153, 392, 475
Personal differences (ego), 115
Personalities, changed, 172
Petition, 553; form, 567
Petit mal, 357
Phobias, 254
Phonisms, 129
Phosphenes, 131
Photisms, 129
Photopsia, 127
Phthisis in asylums, 521
Physical stigmata, 211
Pigmentary disturbances, 529
Pineal, 428
Pinna, deformities of, 213
Pitch, musical, 25
Pituitary, 426
Plasma cells, 451
Plumbism, 387
Polymorphonuclear leucocytes, 582
Polyneuritic psychosis, 408
Porencephaly, 512
Position, sense of, 28
Prefrontal lobes, 79-80
Presbyophrenia, 479
Pressure, intracranial, 463
e intraspinal, 581
np of activity, 155
Pressure-spots, 25
Professions and insanity, 205
Prohibition, 374
Projection, 10, 293
Prolonged bath, 545
Protopathic sensation, 16
Pseudodipsomania, 372
Pseudographia, 159
Pseudolalia, 329
Pseudoparesis, alcoholic, 411
Psychical determinism, 179
Psycho-analysis, 176
Psychomotor hallucinations, 134
Psychoneurosis, 224
Psychoses, 260
Psychosexual trends, 183, 224
Psychotic symptoms, 182
Pupils in general paralysis, 435
Pygmalionism, 197
Pyromania, 258
Pyronin methyl green, 582
Q
Querulant paranoia, 313
592
R
Racial differences, 115
Reaction experiment, 81
Reaction-time, 160
Reactions, 181
Reasoning, 52
Recapture, 588
Reception Orders, 552
Recognition, 49
-F illusions of, 147
Redintegration, 48
Reflex action, 8, 65
», attention, 90
rH diminution of, 164
Registered hospitals, 551
Regression, law of, 13
Religion and insanity, 204
Repressed emotions, 63
Repression, 179, 180
Respiratory hallucinations, 135
Responsibilities of the insane, 560
et seq.
Rest cure, 242
Restraint, 542
Retardation of thought, 140
Retrograde amnesia, 143
Rigidity, katatoniac, 321, 335
Se melancholiac, 266
Rods and cones, 21
Ross-Jones test, 583
Ruffini’s cylinders, 25
S
Sadism, 194
Sapphism, 192
Scavenger cells, 459, 482
Schedules, 567
Schizophrenia, 332
Sclerotic idiocy, 505
Scoptophilia, 195
Seborrheea, 527
Seclusion, 542
Seclusiveness, 332
Secondary sensations, 129
Segmental anesthesia, 234
Seizures in general paralysis, 434
Sejunctive dementia, 332
Senile brain, 478
,,. dementia, 473
,, melancholia, 274
», writing, 163, 476
Sensation, 13
= disorders of, 118
“a epigastric, 128
ae visceral, 121
Sense of movement and position, 28
Sensory apraxia, 152
Sentiments, 104
ye disorders of, 170
Serum Moebius, 250
Sex and station, 173
MIND AND ITS DISORDERS
Sex abnormalities, 191
», glands, 429
Sexual development, 185
5, differences ie
;, “@XCess, a5
» hallucinations, 134
» Jnstinci ares
,, inversion, 192
5° ~perversion, 0%
theory, 183
Shell- shock, 208, 231
Shock, 203
Simian hands, 216
Simple dementia pracox, 332
i, Manid, gor
Single care, 551
Skin affections, 218, 264, 527
Sleep, 96
,, theories of, 98
Sleeping draughts, 545
Sleepy sickness, 468
Smell, 121
», hallucinations of, 132
Sodomy, 191-2
Softening, cerebral, 467
Soneryl, 546
Soured milk, 280
Space-perception, 40
Speech, 10g
,, disorders of, 158, 268, 441
Spider cells, 548-9
Spiritualism, 4
Sidbchen cells, 458
Staining methods, 575
Stammering, 497
Statement of particulars, 553
Static sense, hallucinations of, 135
», Space-perception, 40
Status epilepticus, 370, 434, 446
Stereotypy, 157, 329
Stigmata, physical, 211
“Stocking ’’ anesthesia, 234
Strumpell’s case, II
Strychnine in exhaustion, 396
Stupor, anergic, 295
- epileptic, 361
- katatoniac, 335
oP melancholiac, 273
Stuttering, 497
Sublimation, 180
Suggestibility, 404, 442, 480
Suggestion, 244
Suicidal impulses, 258, 290
Suicide, 281
», legal aspects of, 565
+, prevention of, 548
Sulphonal, 546
poisoning, 278
Summary Reception Orders, 552, 555
Superficial reflexes, 286
Suprarenals, 428
INDEX
Survival of the unfit, 200
Symbolism, 189
Sympathetic insanity, 188
Synesthesiz, 129
Synapses, 7
Synaptic resistance, 7
Syphilis and general. paralysis, 431
Syphilitic idiocy, 505
Systematized anesthesia, 126
it
Tabes in general paralysis, 434
Tactile hallucinations, 133
Taste, 121
», contrasts, 27
he Geiect Of,°121
» hallucinations, 132
», sensations, 26
ye the sense of, 121
Telepathy, 17
Temperaments, 60
Terminal dementia, 299
Testamentary capacity, 559
Then-ness, feeling of, 43
Thought, train of, 47
Thoughts, irrepressible, 254
Thymopsyche, 331
Thymus, 429
Thyroid, 419
Thyroigenous insanity, 419
Thyro-iodine, 420
Tics, 236
Tigroid substance, 5
Timbre, 25
Time-perception, 42
Tolerance of alcohol, 400
Tone of feeling, 54
Torts, 561
Touch-spots, 25
Toxic insanity, 388
Train of thought, 47
Transfer, 588
Transference, 189
Traumatism, cranial, 467
Tribadism, 192
Tricks, 327
Trional, 278, 547
Trophoplasm, 5
Tube feeding, 543
Tubercular meningitis, 467
veh peritonitis, 489
Tumours, cerebral, 464 .
U
Unconscious, the, 179
action, 84
63 associations, 52
+ attention, 90
>”
593
Unconscious emotion, 63
st mentation, II
fi: percepts, 45
‘ sensations, 28
Ulcerative colitis, 524
Ulnar anesthesia, 438
Unity of ideation, 33, 129, 168
», Of mentation, 117
Uremia, 490
Urgency Order, 555; form, 569
Urine in delirium tremens, 404
», in epilepsy, 364
», in mania, 284
», in melancholia, 265
Urnings, 192
Urticaria, 531
Valerian, 232
Verbigeration, 158, 330
Verbochromia, 129
Veronal, 279, 546
Visceral hallucinations, 134
sensations, I2I
Visceroptosis, 239
Vision, 20
» diminution of, 120
», hallucinations of, 131
Visits from friends, 548
Visual space-perception, 33
| Vitiligo, 529
Volition, defect of, 226
Voluntary action, 78
ay attention, 88
nA boarders, 552
Voyeurs, 190
W
| Wandering lunatics, 552, 555
War and insanity, 208, 231
Warm-spots, 26
Warmth, hallucinations of, 133
Warning in epilepsy, 354
Wassermann reaction, 585
Weaning from chloral, 383
from cocaine, 382
ne from morphia, 397
Weber’s law, 19
Weigert-Pal stain, 577
Weigert’s stain for neuroglia, 578
Weir Mitchell treatment, 242
Wet pack, 545
Wig collectors, 196
Witnesses, insane aS, 559
Witselsucht, 405
Wrinkling in dementia precox, 322
az in melancholia, 266
Writing of the insane, 159, 268, 392,
412, 443, 476
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H. K. LEWIS & CO. LTD., 28, GOWER PLACE, LONDON
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