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OME: OME oa en rep aeenegemeene mamcraranconioneranarannenes teenie nah eee a EE A AT AAT Ne eee eINeNEeneD UMM ne nr ne nn, meen ee een Subsnaensinariestrvions Paesaustanienmemnareansamyiorenemeneametaeny eee LE a a ts ewan ror — ee pee ee et Lannnrsathatnstunesiubenapesdiussenmrenessoanmnoameancemeenionmen ean SaaS oe —< a Ae |p een seroma aeons ~ — Oe A OS ee gfe geeneme — en 6e ee Seperens . ne er paesienpmamay eases -catestnseash-oeanestsnstnanse es-oeeme yamine amsmeen aeetremerennan moreno oe meen eee ne OO A LOO AT EL OT ETAT IAD wee ae nes cena cn re [tetienegieeranot-aateeeenennnenmateripeoeeeeaatenanr ST TOT OTT - a ae oe nee nee te ane pet ert Naan vase ee * ana ner mais a ep eonareramaenrreeneenioanio ee nena eee NRT Sen poceaion = > > ne ene cr en anieapcineeeeiaeapepeenneonemebaeer ene EE OT IT TNE ITA —— pemetate ~- — ve ener aaa ne nN a ee tee ate ume - eet ve Se TL TD, — — er ee i= SN a a nen sagen ee ae eerie TT LN eee - pe ans monger en en oO a Kae “hereneone - ~ TT Te ne eran ane « en nT a ee =. re LE ST TT LT TOT — tes < Senncusannwemeoncunqcuenenincreomaeereeenaeenee eee eA Sen a TS aeons ~ — re ~ A a ee cana dy eer enn wainarenend-ooninangpormnmane a ayy ove a STENTS Rr een Ae donee tiv haaptasnaravasnasenatos eoeerensernanensoeonennaete-sortnom ee anes aes ~~ = - Oa Nee A NAO Ben = — ates — a aT a a tr pO a ee pane navinn- ani -— en ym enon ene arene eens eae SS RR IR ae ee —e — ae moras ~~ ~ rene re raya NN nm en eo = epoca vm 7 = uae oe ee a amentore ~ ~ — on ee lee = ~ - ——— = - ~ - - _ on one - - 7 - - —— - om a mr nr ce inlet — errno am . esses tras UA antennae apeanenmpeetencemeresee canon menereriree ere eee ee TT ee preston natasisaainepageeeieiphceee-orepetenteh:teecammenmmeeamenetiezaene meee ee ta ee RE — = _ ss a = - _ art Pee ne Eero te oe . 2 ee i ee ee Sor RE NS Nk 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 - e ee ad SS . f : 7 - - v P : ‘ , vom . Ad : Seed a Pe ; 7 der a a iid hh Raw’ - Mei che bs i ay 4 ; 4 ' rae " , ' ; : : a tbeed . eee i A. fa a é ; b 1 ‘ a ay 7.40 Shap ' a e- ; - . — i ’ C s Val Gl 4 | ¥ . 4 = -_ : _ ; -s ' | é - | ; , @ , ie D aC 1! ae é. ql iw iif +i » oat i = : . 7 @ ~ ‘ . a —_ Lan | - : % ga Met oe ' 4 ’ an, eo P re at md pdb caacln: ts aehageaceat inane ' 7 - A “4 / rva 7 ’ A - e J he . ¢. -. 7 . , -a5 ~~ ms 7 i . nt, i i . a ( : ies ~ Z- — oy @ Ca i nies = oa ree ee er US ALON 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- en tne ene nn ee ee ee eee eee, . ROLANDIC AREA NUCLEI GRACILIS AND CUNEATUS / eee ¢ AUDITORY NUCLEUS ASSOCIATION AREAS ISLAND OF x uw) = aa O O “f < ag a0) Ww od uJ LIMBIC PROJECTION O LOBE AREAS m —_— ? + OLFACTORY OPTIC BASAL BULB THALAMUS] GANGLIA STATIONS OF DIVERGENCE TO CEREBELLUM PAPILLAE (-} es GANGLION BIPOLAR GANGLIA SPIRALE GENICULATE CELLS GANGLIA ' G TACTILE A, CORPUSCLES ' CELLS : [RODS AND OF Pp CONES LINGUAL ERIPHERY ' 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. (c) Chorda tympaniand glosso- (e) Posterior columns. (g) Auditory (2) Lateral fillet. (¢) Centrum ovale. To face p. 10 He P78 RY ghia MIVERSITY OF ILLUS ae! * aa) | we - DP ht —_ o- aie roe a . ¢= : : ae ae a a a “Te » Cl vast ike © = oot + eles a _ al va 7 = ae. a ' . 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 ) 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. 0) “oo 2 nes yee ras) > ial e& i o aa o n CS uy ao} Ee = Aa, 3.80 ie ss iho a ibaa i) oe OH > nwa ss p q 77} seg Be 33a BEEGO mw 8a ope a ES =o 8 9 ce area CS am ba tote = oon a3 asnod ~ SsBaa8 a g@ao o (0) Oe, sO & eeu Th © Oo0O9NM 0 o BAwds a Sameer ars RE) fas] he course of a pro- lancholia. 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 » tt oe 3a * 7 v1, ‘ — : eo eo oe —— Aa Per oe : OF THE -¢ ) RSITY GF ILLINOIS UNIVERS OL nee oe | Pe i tad erie eee ; PS : ' nd ‘ Meee - ‘ : 7 8 eee er ew = ee ee . bad ; joey. ee ee coeth oalaal ‘ te eee eA re i‘ : . as é a + 5 — 7 * ‘ 2 ‘ j > : io« 4 we : 5 ’ ; : ree i : ’ ie 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 Be hth all their ae Reel ; pei till loved laces. riban ugles, Br one Opie Syn is tay ee hel retained ‘a passion for her paduasoy, because I formerly Fa Nt Cmte happened to say it became her: Be tlm hon, . and by ali wetont, and be weve ‘ we put tnt wetny come a ale ‘tay “yw my 4 tree Ne wumptaary cdicts could * not restrain How well wo fever TD fancied my lectures: against pride had con quered the vanity of my Wiughtors yet J still found them sceretly attached & 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. Zoe Poe faa eff ede ered pe flat ee Ufo ele caer taceeevaraes COREE ECE i \aaae aN ae NC PEE ANCA INIT TI | Hours or Steep SC oN OU Pe Wh p+ aaaeaes i ans Sy BP est bp | he] a22caum mei ere ited 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 -* oe = . - r a ® » L » ‘ = - _ - i 7 i ’ - = ’ 4 - AM sy - re ‘ »@ 7 “ ‘ « = ‘ 4 re - — %y ne ‘ F 7 "Saws al . - t %) * ” ’ . o . « 2 Ole Vad Sd UO 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). N es ‘jenba oq 03 pezrusodal o1¥ sited 4se] 9914} 94} Jo OM} UBYM passed oq 0} PeLapISUOd ST 4s9} BY], “UOTJSASdNs STY} JSISOI IDAO IO ZI AjI[eJUSU JO S[eNPIAIpUy ‘Y4Susyz [enba jo ore saury oy} YoryM ur sired 9914} I9MOT oY} JO 9UIeS OY} Avs 01 AOUAPUd} & ST 9I9Y} PUP 19] 94} UeY} I9SUOT ST JYSt1 oy} sired 9914} 4sIY 9YW UL ‘OM} 94} JO IasUOT 94} ST YOIYM payse soutwrexe oy} pue ioded jo sjoays o}e1edas uo patdoo aq prnoys souty jo sited oy] "19 ‘DI 22) oe. ) ea) fe 7, SA AS ATR St SET EE TE IE IBLE. IE ET TIE ST EE CE: I IE ET je) = — A . fH a ———— ea Zz _ = 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 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 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-..” 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 >”? H. K. LEWIS & CO. LTD., 28, GOWER PLACE, LONDON —— : Ss : oS = . age { ae - a — em . > s ee _ ty ’ he it rays, ha ag D ‘ | URBANA 1, | | 4 So = all = wu So > ~ ” c bu = = pom | wo N fo) pues wo @~ *” — ao wo o c 3 0112 02 TL MIND AND ITS DISORDERS 3D ED. euatsto peri > . - . co ne 0 eT a 8 np etre ee . res e aes * oa + - annem scien Ie Ee SIT ONAL NTA ta AY Oe RR RENE NERS | OT WBE OEM IN EMEADORD TPOULTTTAT roast APO ee meet anata eee nNag annetnennt paler sumemrnrrensercwnterarsepesienet eee igthipeeatonataententy - Sista a si Poe eR Re Reet ee EEE TE TE TPT PLT SES PTET IS A NOTA OROR RISE NOs Aeabagsoebsantaws sim amine meme ce a oo tne sevens a -_ . = - eH caupixtooyipiadeniige-anuendepeamneaion 2 we : : : NAAN ESSE ET tS whe hye RPL