Skip to main content

Full text of "Textbook of psychiatry"

See other formats


UNIVERSITY 
OF  FLORIDA 
LIBRARIES 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Lyrasis  IVIembers  and  Sloan  Foundation 


http://www.archive.org/details/textbookofpsychiOObleu 


TEXTBOOK 
OF    PSYCHIATRY 


BY 

Prof.  Dr.  EUGEN  BLEULER 

DIRECTOR    OF    THE    PSYCHIATRIC    CLIKIC,    ZURICH 


AUTHORIZED  ENGLISH  EDITION 

BY 

A.  A.  BRILL,  Ph.B.,  M.D. 

FORMER    ASSISTANT    PHYSICtAN    OF    THE    CENTRAL   ISLIP    STATE    HOSPITAL    AND    ASSISTENZ- 

ARZT    OF    THE    CLINIC    OF    PSYCHIATRY,    ZURICH.       LECTURER    ON    PSY'CHOANALY'SIS 

AND    ABNORMAL   PSYCHOLOGY,    NEW    YORK    UNIVERSITY 


THE  MACMILLAN  COMPANY 
1934 


/"S  2. 


COPYBIGHT,    1924, 

By  the  MACMILLAN  COMPANY. 


All  rights  reserved — no  part  of  this  book  may  be 
reproduced  in  any  form  without  permission  in  writing 
from  the  publisher,  except  by  a  reviewer  who  wishes 
to  quote  brief  passages  in  connection  with  a  review 
written     for     inclusion     in     magazine     or     newspaper. 

Set  up  and  printed.  Published  January,  1924. 
Reprinted  July,  1924;  June,  1930.  Reissued 
January,  1934. 


PRINTED  IN  THE  UNITED  STATES  OF  AMERICA  BY 
THE  FERRIS  PRINTING  COMPANY,  NEW  YORK 


TRANSLATOR'S  PREFACE 

When  after  about  five  years  in  the  New  York  State  Hospital  I 
entered  Burgholzli,  the  clinic  of  psychiatry  at  Ziirich,  I  found  a  new 
spirit  in  psychiatry  there.  Having  been  accustomed  to  look  at  pa- 
tients through  the  eyes  of  the  German  psychiatry,  as  notably  repre- 
sented by  Kraepelin,  Professor  Bleuler's  ways  impressed  me  not  only  as 
more  interesting  but  also  as  more  instructive  and  farther  reaching  in 
scope  and  result.  Professor  Bleuler  was  the  first  noted  psychiatrist  who 
recognized  the  great  value  of  Professor  Freud's  discoveries  and  im- 
pressed his  feelings  on  his  co-workers.^  In  Burgholzli  the  psychoanalytic 
methods  were  applied  to  all  accessible  patients,  and  the  Freudian 
mechanisms  were  investigated  even  in  the  organic  psychoses.  This 
resulted  in  many  works  of  great  importance  which  have  exerted  much 
influence  on  psychiatry  and  psychopathology  in  general. ^ 

It  was  while  I  was  Professor  Bleuler's  assistant,  in  1907,  that  he 
spoke  to  me  about  writing  a  textbook  on  psychiatry,  and  I  volunteered 
to  put  it  into  English.  Since  then  I  have  translated  a  number  of  Pro- 
fessor Freud's  works  and  became  closely  identified  with  the  psycho- 
analytic movement,  but  my  interest  in  psychiatry,  through  which  I 
first  became  acquainted  with  psychoanalysis,  has  remained  just  as 
deep.  It  is  therefore  with  a  strong  feeling  of  satisfaction  that  I  present 
this  work  to  English  readers. 

This  translation  was  made  of,  the  author's  fourth  German  edition, 
and  as  far  as  was  possible  "the  .German  text  was -strictly  followed.  The 
only  part  omitted, was  the  addendum  dealing  witli  forensic  psychi- 
atry. The  autho-i:'s  i^eas  are  based  on  the  Swiss,  German/  and  Aus- 
trian laws  which  "are  quite |  different'  from:  ours,  and  as"' ours  are  so 
numerous,  so- -indefinite  and 'so  contradictory  it  was  thought'  best  to 
omit  this  subject  for  the  present. 

This  book  was  primarily  written  to  furnish  the  student  and  the 
general  practitioner  with  a  general  knowledge  of  psychiatry-.  The 
author  endeavors  to  present  clear  concepts,  and  whenever  that  is  not 

^The  works  of  the  Zurich  school  are  too  well  known  to  be  mentioned  here. 

^  For  a  complete  bibliography  of  Bleuler's  works  the  reader  is  referred  to 
Hans  W.  Maier's  paper  on  Eugen  Bleuler,  Zeitschr.  f.  d.  gesammte  Neurologie 
und  Ps3'chiatrie,  LXXXII. 


7^77^ 


vi  TRANSLATOR'S  PREFACE 

possible  he  lucidly  exposes  the  existing  gaps.  He  lays  stress  on  the 
understanding  of  psychology,  because,  to  put  it  in  his  own  words, 
"psychiatry  without  psychology  is  like  pathology  without  physiology, 
and  also  because  a  good  physician  can  be  only  he  who  understands  the 
whole  human  being." 

Dr.  George  H.  Kirby,  Director  of  the  N.  Y.  Psychiatric  Institute, 
and  Professor  of  Psychiatry  at  the  Cornell  University  Medical  College, 
who  is  most  qualified  to  judge  the  development  of  psychiatric  instruc- 
tion in  the  United  States,  has  rendered  a  great  service  by  writing  the 
introduction.  I  am  further  indebted  to  him  for  many  helpful  sugges- 
tions in  the  work  of  translation. 

I  owe  gratitude  also  to  Dr.  M.  S.  Gregory,  Director  of  the  Psycho- 
pathic Pavillions  of  Bellevue  Hospital  and  Professor  of  Psychiatry  at 
N.  Y.  University  Bellevue  Medical  College,  and  Dr.  M.  B.  Heyman, 
the  Superintendent  of  the  Manhattan  State  Hospital,  New  York  City, 
the  former  for  his  encouragement  and  valuable  suggestions,  and  the 
latter  for  a  number  of  handwriting  specimens  of  patients  in  his  hospital. 

A.  A.  Bhill. 
November,  1923. 


INTRODUCTION 

The  appearance  of  a  translation  of  Professor  Bleuler's  textbook 
will  supply  a  need  long  felt  by  psychiatrists  in  English-speaking 
countries.  During  his  twenty-five  years'  service  as  a  teacher  at  the 
University  of  Zurich  and  Director  of  the  Cantonial  Hospital  at  Burg- 
holzli  Bleuler  has  been  a  most  indefatigable  worker  and  painstaking 
investigator  in  the  field  of  psychopathology  and  his  numerous  scien- 
tific contributions  and  original  observations  have  brought  him  inter- 
national recognition  as  an  outstanding  leader  in  the  progress  of 
modern  psychiatry. 

At  least  two  of  Bleuler's  monographic  studies  have  already  been 
translated  into  English.  His  description  and  illuminating  analysis  of 
negativistic  phenomena  was  translated  by  Doctor  William  A.  Whit^  in 
1912  under  the  title  of  "The  Theory  of  Schizophrenic  Negativism."  In 
the  same  year  another  of  his  important  studies,  entitled  "Affectivity, 
Suggestibility,  Paranoia,"  was  translated  by  Doctor  Ricksher.  Ameri- 
can psychiatrists  also  have  had  an  opportunity  to  become  acquainted 
with  another  of  Bleuler's  important  contributions,  a  summary'  of  which 
he  gave  in  an  address  on  "Autistic  Thinking"  delivered  at  the  opening 
exercises  of  the  Phipps  Psychiatric  Clinic,  Johns  Hopkins  Hospital,  in 
1913.  Those  who  had  the  pleasure  of  hearing  and  meeting  Professor 
Bleuler  on  that  occasion  were  immediately  charmed  by  his  pleasing 
personality  and  scholarly  attainments,  as  well  as  impressed  by  his 
ability  to  present  a  complex  subject  in  clear  and  simple  language  and 
to  show  by  a  penetrating  analysis  of  symptoms  how  the  ordinarily  in- 
comprehensible or  illogical  ideas  and  bizarre  reactions  of  dementia 
praecox  had  very  plainly  their  counterparts  in  normal  day-dreaming 
and  in  childhood  phantasy  and  play. 

Of  Bleuler's  special  studies,  that  on  dementia  praecox  is  generally 
conceded  to  be  the  most  important.  This  monographic  work  of  over 
400  pages  was  published  in  1911  as  one  of  the  volumes  of  Aschaff en- 
burg's  Handbook  under  the  title  of  "Dementia  Praecox  oder  Gruppe 
der  Schizophrenien."  Unfortunately  this  work  has  not  been  trans- 
lated although  the  textbook  which  now  becomes  available  in  English 
contains  a  comprehensive  chapter  on  Schizophrenia  (dementia  praecox) 


viii  INTRODUCTION 

with  an  admirable  symptom-analysis,  and  psychological  interpretation 
of  the  development  and  course  of  the  disorder. 

The  first  edition  of  the  textbook  which  appeared  in  1916  was  a 
crystallization  of  Bleuler's  long  experience  as  a  teacher  and  investi- 
gator and  contained  a  systematic  presentation  of  his  important 
psychopathological  formulations  and  their  application  in  clinical 
analysis.  The  warm  reception  accorded  the  book  is  attested  by  the 
fact  that  four  editions  have  already  appeared. 

The  book  marks  a  notable  advance  in  psychiatry  in  that  it  em- 
phasizes sharply  the  contrast  between  the  older  descriptive  psychiatry 
of  Kraepelin  and  the  newer  interpretative  psychiatry  of  the  present 
time  which  utilizes  the  psychoanalytical  principles  and  general  bio- 
logical viewpoints  developed  by  Freud  and  his  pupils  in  Europe  and 
by  Meyer,  Hoch,  White  and  others  in  this  country.  Bleuler  was  ap- 
parently one  of  the  first  psychiatrists  to  grasp  the  great  importance  of 
a  psychodynamic  viewpoint  in  the  study  of  mental  disorders  and 
as  early  as  1906  he  published  a  paper  on  Freudian  mechanisms  in  the 
symptomatology  of  the  psychoses.  Although  he  became  convinced 
of  the  value  and  importance  for  psychiatry  of  many  of  Freud's  for- 
mulations, he  has  always  preserved  a  well  balanced  and  distinctly 
independent  attitude  toward  psychoanalytic  theories  and  in  the  course 
of  his  work  he  has  not  hesitated  to  criticize  certain  aspects  of  the 
Freudian  psychology. 

As  an  introduction  to  the  study  of  clinical  psychiatry  the  physician 
and  the  student  will  find  the  chapters  dealing  with  the  principles  of 
psychology  and  psychopathology  particularly  helpful  and  stimulating. 
While  Bleuler  adheres  to  Kraepelin's  general  scheme  of  classification 
of  clinical  types,  it  will  be  found  that  unlike  Kraepelin  he  does  not 
stop  with  the  mere  enumeration  of  symptoms  but  seeks  through  the 
application  of  psychological  principles  to  give  an  interpretation  and 
explanation  for  the  particular  reaction  type  under  consideration.  This 
applies  not  only  to  the  so-called  functional  mental  disorders  and 
psychopathic  states  but  he  also  discusses  most  interestingly  the  psy- 
chology and  affective  reactions  of  the  toxic  and  organic  syndromes. 

Bleuler's  book  will  be  of  interest  and  help  to  all  those  who  wish 
to  advance  beyond  the  formal  descriptive  psychiatry  of  a  period  now 
rapidly  drawing  to  a  close.  Teachers,  practicing  neuropsychiatrists 
and  state  hospital  physicians  will  find  the  book  to  be  of  great  value  and 
assistance  in  their  clinical  work,  as  it  will  furnish  them  a  comprehen- 
sive presentation  of  the  principles  of  modem  psychiatry  and  their 
practical  application  in  a  form  not  hitherto  available  in  a  psychiatric 
textbook.    It  is  a  work  which,  as  already  intimated,  marks  a  distinct 


INTRODUCTION  ix 

advance  beyond  the  boundaries  of  the  Kraepelinian  psychiatry.  To 
Doctor  Brill,  a  former  pupil  of  Blculcr's,  the  profession  is  indebted  for 
the  successful  completion  of  the  difficult  task  involved  in  the  trans- 
lation. 

George  H.  Kirby. 
Psychiatric  Institute, 
Sept.  1, 1923. 


CONTENTS 


PAOK 


Translator's  Preface   v 

Introduction    vii 

CHAPTER 

I    Psychological  Introduction    1 

The  Psychological  Principles    1 

The  Psyche  1 

Consciousness    2 

Concerning  the  Theory  of  Cognition 3 

The  Unconscious    8 

The  Individual  Psychic  Functions  10 

a)  The  Centripetal  Functions  12 

Sensations    12 

Perceptions    12 

b)  Concepts  and  Ideas  13 

Concepts  13 

Ideas   16 

c)  The  Associations,  Thought 17 

d)  The  Intelligence   23 

e)  Memory    28 

/)     Orientation 32 

g)     Affectivity    32 

h)     Attention    40 

i)      Suggestion    42 

k)     Dereistic  Thinking 45 

I)      Belief,  Mythology,  Poetry,  Philosophy  47 

m)    The  Personality,  the  Ego  49 

n)     The  Centrifugal  Functions 50 

II    General  Psychopathology   54 

1.     Disturbances  of  the  Centripetal  Functions 55 

Disturbances  of  the  Sensory  Organs  55 

Central  Disturbances  of  the  Sensations  and 
Perceptions  (Hyperesthesia,  Anesthesia,  An- 
algesia. Perception,  Comprehension,  Illu- 
sions, Hallucinations)    56 

xi 


xii  CONTENTS 


PAGE 


2.  Disturbances  of  Concepts  and  Ideas 68 

3.  Disturbances  of  Associations  and  of  Thought. ...  71 

General  Facilitation  of  the  Psychic  Processes. 

Flight  of  ideas 71 

Melancholic  Retardation  of  Associations   (In- 
hibition)      74 

Associations  in  Organic  Psychoses 74 

Schizophrenic     (Dreamlike)     Disturbances    of 

Association 77 

Associations  of  Oligophrenics 82 

Associations  of  Epileptics 82 

The  Associations  of  Hysteria 84 

Associations  of  Neurasthenics  84 

Associations  of  Paranoiacs    85 

Other  Disturbances  of  Association  85 

Confusion  86 

Diffuseness  and  Circumstantiality 86 

Overvalued  Ideas,  Obsessions  (Obsessive  Acts)  87 

Delusions    90 

4.  Disturbances  of  Memorj^ 97 

5.  Disturbances  of  Orientation   110 

6.  Disturbances  of  Consciousness  Ill 

Clear  Mindedness   (Besonnenheit)    116 

7.  Disturbances  of  Affectivity 117 

Morbid  Depression 119 

The  Pathological   Elated   Mood    (Exaltation, 

Euphoria)     122 

Morbid  Irritability 123 

Apathy    124 

Variable  Duration  of  the  Affects 124 

Emotional  Incontinence 125 

Affective  Ambivalence 125 

Congenital  Deficiency  and  Perversions  of  Par- 
ticular Affective  Groups  126 

Exaggerations  and  Onesidedness  of  the  Affec- 
tive Causes,  Morbid  Reactions  126 

Pathology  of  Affective  Disturbances  131 

8.  Disturbances  of  Attention  133 

9.  Morbid  Suggestibility  135 

10.     Disturbances  of  Personality   137 


CONTENTS  xiii 

11.  Disturbances  of  Centrifugal  Functions  (Actions, 
Weakness  of  Will,  Stupor,  Inhibited  Actions, 
Akinesis,  Hyperkineses,  Stereotypes,  Morbid 
Impulses,  Compulsive  Actions,  Katalepsie, 
Negativisms,    Inadequate    Manifestations    of 

Affects,  Speech  Anomalies,  Writing  Anomalies)  142 

III  Physical  Symptoms    157 

IV  The  Manifestations  of  Mental  Diseases  161 

Morbid  States  161 

Syndromes    164 

V    The  Course  of  Mental  Diseases 167 

VI    The  Borderlines  of  Insanity  170 

VII    Classification  of  Mental  Diseases  173 

VIII    The  Recognition  of  Insanity 184 

IX    Differential  Diagnosis  193 

Compilation   of  the  Differential  Diagnostic   Signifi- 
cance of  Individual  Symptoms 194 

Disturbances  of  Perception 194 

Disturbances  of  Association 195 

Disturbances  of  Orientation 196 

Disturbances  of  Memory 196 

Affective  Disturbances    197 

Some  Special  Syndromes  198 

X    Causes  of  Mental  Diseases  200 

XI    The  Treatment  of  Mental  Diseases  in  General 214 

XII    The  Significance  of  Psychiatry 226 

XIII    The  Individual  Mental  Diseases 230 

L-V.     The  Acquired   Psychoses  with   Coarse  Brain 

Disturbances.    The  Organic  Syndrome  ....  230 

I.     Insanity  in  Injuries  to  the  Brain 240 

II.     Insanity  in  Brain  Diseases 242 

III.  Syphilitic  Psychoses    244 

IV.  Dementia  Paralytica  250 

V.     Senile    and    Presenile    Insanity    (Senile   Psy- 
choses)      276 

Presenile  Insanity 279 


xiv  CONTENTS 


PAGE 


Arteriosclerotic  Insanity   279 

Senile  Dementia   (Simple  Dementia  Senilis)  286 

Presbyophrenia    294 

VI.     The  Toxic  Psychoses 299 

1.  The  Acute  Toxemias  299 

Pathological  Drunkenness 300 

2.  The  Chronic  Intoxications  303 

A.  Chronic  Alcoholic  Poisoning 303 

The  Simple  Drinking  Mania  ...  303 

Delirium  Tremens    326 

Alcoholic  Hallucinosis  341 

Alcoholic  Psychoses  with  Or- 
ganic Symptoms  345 

The  Alcoholic  Korsakoff  Psy- 
chosis      346 

Alcoholic  Pseudoparesis    350 

Polioencephalitis  Superior 350 

Alcoholic  Leukencephalitis  of  the 

Corpus  Callosum   351 

Chronic  Delusions  of  Jealousy  in 
Alcoholics  and  Alcoholic  Para- 
noia    351 

Dipsomania    351 

Alcoholic  Epilepsy   353 

Alcoholic  Melancholia  354 

B.  Morphinism   354 

C.  Cocainism 359 

VII.     Infectious  Psychoses   361 

A.  Fever  Deliria    362 

B.  Infectious  Dehria  363 

C.  Acute  Confusion,  Amentia   364 

D.  Infectious  States  of  Weakness 365 

VIII.     Thyreogenic  Psychoses   365 

Psychoses  in  Basedow's  Disease 365 

Myxoedema   (Cachexia  Strumipriva)    366 

Endemic  and  Sporadic  Cretinism 367 

IX.     Schizophrenias   (Dementia  Praecox)    372 

A.  The  Simple  Functions  373 

B.  The  Complex  Functions  384 

C.  The  Accessory  Symptoms 387 


CX)NTENTS  XV 

TAtm 

D.  The  Subdivisions  (Paranoid,  Catatonia, 

Hebephrenia,  Schizophrenia  Simplex)  413 

E.  The  Course    434 

F.  What  Is  Included  under  the  Term 436 

G.  Combination     of     Schizophrenia     with 

other  Diseases 437 

H.     Diagnosis     438 

I.     Prognosis    440 

K.     Causes    441 

L.     Frequency  and  Prevalence  442 

M.    Anatomy  and  Pathology  442 

N.     Treatment    443 

X.     Epilepsy     445 

XI.    Manic-Depressive  Insanity   465 

XII.  Psychopathic   Forms    of   Reaction    (Situation 

Psychoses)    493 

1.  Paranoia  510 

2.  The  Delusion  of  Persecution  of  the  Hard 

of  Hearing  533 

3.  Litigious  Insanity 533 

4.  Induced  Insanity  (Folie  a  Deux)   534 

5.  The    Reactive    Mental    Disturbance    of 

Prisoners    535 

6.  The  Primitive  Reactions 537 

7.  Reactive  Depressions  and  Exaltations. .  537 

8.  The  Reactive   Impulses    (Impulsive   In- 

sanity of  Kraepelin)    538 

9.  The  Reactive  Changes  of  Character  ....  540 
10.    The  Neurotic  Syndromes 540 

A.  Hysterical  Syndrome  "Hysteria"..  540 

B.  The   So-Called   Neurasthenic   Syn- 

drome.   Neurasthenia  and  Pseu- 

doneurasthenia    556 

Actual  Neurasthenia,  Chronic  Ner- 
vous Exhaustion  557 

The  (Pseudo-)  Neurasthenias  ....  558 

C.  The  Expectation  Neurosis   560 

D.  The  Compulsion  Neurosis   560 

E.  The  Accident  Neuroses 564 

XIII.  The  Psychopathies 569 

A.    Nervosity   571 


xvi  CONTENTS 

CHAPTER  PAGE 

B.  The  Aberrations  of  the  Sexual  Impulse.  572 

C.  Abnormal  Irritability    582 

D.  Instability    582 

E.  Special  Impulses  586 

F.  The  Eccentric  (Verschrobene)   587 

G.  Pseudologia     Phantastica     (Liars    and 

Swindlers)     587 

H.  Constitutional  Ethical  Aberrations 
(Enemies  of  Society,  antisocial  be- 
ings, moral  oligophrenics,  moral 
idiots,  and  imbeciles.  Moral  Insan- 
ity)         587 

I.     The  Contentious   (Pseudo-Litigious)    . .     591 

XIV    Oligophrenias   (Psychic  Inhibitions  of  Development) . .     593 


ILLUSTRATIONS 


P/l'.K 


1.     Paretic  expression   251 

2-     Paretic  expression  252 

3.  Paretic  writing 253 

4.  Cortex  in  paresis  262 

5.  Normal  cortex   264 

6.  Gliosis  in  paresis  265 

7.  Round  cell  infiltration  266 

8.  Plasma  cells   269 

9.  Senile  writing  291 

10.  Pyramidal  cell  in  senility   293 

11.  Presbyophrenic 295 

12.  Cortex  in  presbyophrenia    297 

13.  Plaques  in  presbyophrenia   298 

14.  Plaques  magnified  298 

15.  Normal  cortical  cell   299 

16.  Writing  of  a  chronic  alcoholic 305 

17.  Writing  of  a  delirious  patient 334 

18.  Cretin     !^ 368 

19.  Two  cretins  in  profile 369 

20.  Myxoedematous  cretin  370 

21.  Cretin  excitation   371 

22.  Hebephrenic    381 

23.  Catatonic     382 

24.  Hebephrenic  writing  395 

25.  Schizophrenic  writing  396 

26.  Paranoid  praecox  writing 397 

27.  Drawing  by  paranoid  praecox  399 

28.  Letter  of  schizophrenic  patient   401 

29.  From  a  note  book  of  a  chronic  catatonic 402 

30.  Catatonic   attitude    403 

xvii 


xviii  ILLUSTRATIONS 

Pig.  page 

31.  Permanent  catatonic  attitude 404 

32.  Stereotyped  attitude  405 

33a  and  33b.     Snout  cramp  406 

34.  Grimacing  catatonic  408 

35.  Manic  schizophrenic  woman  409 

36.  Chronic  catatonic  women   421 

37a.    Manic  writing   470 

37b.     Manic  writing   471 

38.  MelanchoHc  expression 472 

39.  Veragutii's  fold  of  upper  lid  in  depression 473 

40.  Normal  fold   473 

41.  Writing  of  depressed  patient 477 

42.  Mixed  condition  in  constant  euphoria   480 

43.  Imbecile  somewhat  microcephalic   605 

44.  Imbecile   laughter    606 

45.  Pygrocephalus    607 

46.  Microcephalus    608 

47.  High  grade  microcephalic   609 

48.  Cerebral  infantile  paralysis   610 

49.  Idiot  612 

50.  Idiot  613 

51.  Microgeria  in  imbecile 614 


TEXTBOOK  OF  PSYCHIATRY 


TEXTBOOK  OF  PSYCHIATRY 

CHAPTER  I 

PSYCHOLOGICAL  INTRODUCTION 

THE  PSYCHOLOGICAL  PRINCIPLES  ^ 

The  Psyche 

The  human  psyche  is  so  largely  dependent  in  all  its  functions  on 
the  cerebral  cortex  and  on  this  alone  that  it  is  said  to  be  located 
there.^  But  not  all  functions  of  the  cerebral  cortex  belong  to  the 
complex  which  we  ordinarily  call  psychic.^  Thus  what  has  been  called 
psychic  fluctuations  of  the  vascular  tone  or  of  the  secretions  are 
cortically  directed  functions,  which  though  depending  on  the  psyche 
in  some  manner  are  not  psychic. 

Like  the  reflex  mechanism,  the  purpose  of  the  psyche  is  to  receive 
external  stimuli  and  to  react  to  them  in  a  manner  beneficial  to  the 
individual  or  the  genus.  There  are,  however,  great  differences  between 
the  two  modes  of  reaction.  The  influence  exerted  upon  a  reflex  through 
a  stimulus  other  than  the  one  initiating  it  (or  the  initiating  and  direct- 
ing group  of  stimuli),  is  so  limited  qualitatively  and  quantitatively, 
that  we  ordinarily  take  no  account  of  it.  On  the  other  hand,  in  the 
psyche  this  influence  is  qualitatively  and  quantitatively  almost  unlim- 
ited. It  is  particularly  noteworthy  that  not  only  actual  stimuli  play 
an  essential  part  in  determining  the  reactions,  but  also  former  stimuli, 
especially  ''experiences"  and  "memories";  on  the  other  hand,  such 
memory  effects  play  a  very  slight  part  in  the  reflexes.  In  other  words, 
the  reflex  always  reacts  in  the  same  manner  to  the  same  stimulus,  while 
the  psyche  has  infinite  possibilities  of  reaction,  which  are  highly  com- 
plex  and  plastic,  that  is,  they  differ  with  the  same  stimulus  according 

^Comp.  Bleiiler  Naturgeschichte  der  Seele,  Springer,  Berlin,  1921. 

"  In  many  vertebrates  evidently  not  all  psychic  functions  have  gone  into 
the  cerebral  cortex;  that  is  particularly  true  of  the  lower  ones.  Even  in  man 
there  is  still  some  connection  between  basal  ganglia  and  affectivity. 

*  Contrary  to  general  assumptions,  the  line  of  demarcation  between  psychic 
and  non-ps.vchic  cortical  functions  is  quite  indefinite.  It  is  certain  that 
only  small  parts  of  the  cortical  functions  are  conscious.  (Cf.  Section  on 
"Unconscioua.") 

1 


2  TEXTBOOK  OF  PSYCHIATRY 

to  the  particular  circumstances,  while  those  of  the  reflexes  are  simple 
and  very  stable.  Thus  as  far  as  objective  conditions  are  concerned 
the  difference  between  reflex  and  psychic  reaction  is  enormous  in  de- 
gree, but  none  in  principle.  An  absolute  difference  is  ordinarily 
assumed  on  the  subjective  side,  whether  correctly  or  incorrectly  no  one 
can  tell  (Pflueger's  spinal  cord  soul!)  The  assumption  is  that  only 
psychic  functions  can  become  conscious  but  not  reflex:es. 

Consciousness 

Some  authors  consider  consciousness  as  the  very  essential  quality 
of  psychic  processes.  It  is  an  indefinable  something,  a  quality  of  the 
same,  in  fact  that  quality  which  most  clearly  differentiates  us  from 
an  automaton.  We  can  imagine  a  machine  which  will  perform  com- 
plicated reactions  but  we  will  never  ascribe  consciousness  to  an  ap- 
paratus constructed  by  us,  that  is,  we  cannot  assume  that  it  ''knows" 
what  it  is  doing,  that  it  "feels"  the  influences  of  its  environment, 
that  it  knows  the  "motives"  of  the  reaction.  The  same  idea  is  ex- 
pressed by  the  word  "conscious,"  when  we  inquire  whether  someone 
has  consciously  or  unconsciously  arranged  his  hair. 

To  compare  consciousness  with  a  form  which  has  for  its  content 
conscious  processes  is  misleading.  Nor  can  one  do  anything  in  psycho- 
pathology  with  such  a  definition  as  "the  sum  of  all  real  or  simultane- 
ously present  ideas"  (Herbart),  which  is  about  what  one  would  call 
the  actual  psyche.  We  cannot  get  along,  however,  without  differ- 
entiating between  conscious  and  unconscious  psychic  processes  on 
the  one  hand,  and  between  psychic  and  physical  on  the  other.* 

Wundt  defines  consciousness  as  the  "association  of  the  psychic 
structures."  This  definition  is  also  used  elsewhere  in  the  concepts 
referring  to  the  "disturbances  of  consciousness,"  where  it  is  merely  a 
question  of  a  disturbance  in  the  association  of  the  psychisms.  Con- 
sciousness in  our  sense  cannot  very  well  be  disturbed;  it  is  either 
present  or  absent  On  the  other  hand,  extent  and  clearness  of  con- 
sciousness are  relative  terms.  The  extent  of  consciousness  corre- 
sponds to  the  number  of  the  (actually  or  possibly)  simultaneously 
existing  conscious  ideas,  and  clearness  of  consciousness  depends  on 
the  completeness  of  one  conscious  concept  or  on  one  idea  of  a 
partially  forming  concept,  as  well  as  on  the  degree  of  exclusion  of 
irrelevant  ideas. 

The  psychism  itself  and  not  a  mere  quality  or  form  of  it  is 
involved  in  expressions  like  "consciousness  of  time  and  place"  for 
which  we  had  better  substitute  "orientation  as  to  time  and  place." 
*  See  pp.  7-8. 


PSYCHOLOGICAL  INTRODUCTION  3 

The  expression  "dual  consciousness"  for  "dual  personality"  is  ju«t 
as  inappropriate.'^ 

Furthermore,  one  is  inclined  to  assume  consciousness  in  our  sense, 
when  one  observes  purposive  actions.  This  is  not  correct,  for  even 
reflexes  may  be  purposive;  even  an  automaton  may  react  differently 
to  different  situations,  as  in  the  case  of  automatic  scales  in  the  mint. 
The  ability  to  remember  a  certain  experience  has  often  been  con- 
sidered as  a  sign  that  consciousness  had  been  present,  and  it  has 
also  been  said  that  an  action  performed  in  a  twilight  state  has  been 
"without  consciousness."    This  is  also  wrong. 

Likewise  one  should  not  identify  "conscious"  and  "voluntary." 
The  act  of  dressing  oneself  is  usually  voluntary,  but  not  conscious, 
whereas  compulsive  actions  are  conscious,  but  not  voluntary,  that  is, 
they  are  contrary  to  our  will.  And  neither  of  these  holds  good  in 
automatic  actions  like  scratching  oneself,  mimicking  motions,  etc. ;  and 
in  pathological  automatisms.^ 

Concerning  the  Theory  of  Cognition  ^ 

Consciousness  is  said  to  differentiate  psychic  from  physical  occur- 
rences. Two  fundamentally  different  series  of  experiences  have  been 
assumed,  those  that  refer  to  the  "inner  life,"  to  that  which  "takes  place 
merely  in  time,"  the  conscious  or  the  psychic,  and  those  experiences 
which  refer  to  the  outer  world  or  to  that  which  has  extent,  namely,  the 
physical. 

The  relationship  between  these  two  forms  of  experiences  is  dif- 
ferently conceived.  Most  suitable  for  the  naive  mind  is  the  conception 
of  Dualism,  which  assumes  a  carrier  of  consciousness  independent  of 
the  body.  One  sees  the  body  remaining  after  death,  while  all  psychic 
manifestations  disappear  with  the  cessation  of  life.  The  "soul,"  used 
here  according  to  the  earlier  views,  representing  not  only  the  psychic, 
but  a  fusion  with  the  term  life,  has  separated  itself  from  the  body. 
That  it  has  not  simply  been  resolved  into  nothingness  is  sho^Mi  by 
its  reappearance  in  dreams,  in  waking  hallucinations,  and  in  the 
illusions  of  those  who  survived.  And  that  the  observer's  own  soul 
can  free  itself  from  his  body  is  shown  by  his  dream  experiences,  during 
which,  regardless  of  time  and  space,  he  perceives  things  which  are 
far  removed  from  his  motionless  body. 

^Disturbances  of  Personality,  p.  137. 

"The  subject  of  "self-consciousness"  uill  be  discussed  at  the  end  of  the 
chapter  on  personality,  p.  50. 

'  Ziehen,  Zum  gegenwartigen  Stand  der  Erkenntnistheorie  Wiesbaden,  Berg- 
mann,  1914, 


4  TEXTBOOK  OF  PSYCHIATRY 

Dualism  is  an  essential  constituent  of  religions ;  it  has  been  attacked 
for  thousands  of  years  and  is  at  present  still  rejected  by  most  sci- 
entists. Its  most  important  fundamental  elements,  the  dream  experi- 
ences, and  the  apparitions  of  spirits,  have  proven  illusory,  and  what 
is  more,  it  has  been  shown  that  the  psychic  functions  of  man  are  in 
all  respects  dependent  upon  the  brain.  On  the  other  hand,  it  is  self- 
evident,  even  if  one  does  not  always  bear  it  in  mind,  that  in  reality 
the  physical  world  cannot  at  all  be  as  we  perceive  and  imagine  it, 
and  finally,  every  certain  proof  is  lacking  that  iV  even  exists. 

Thus  monistic  views  have  been  formed  regarding  the  relationship 
of  the  two  series.  They  can  be  divided  approximately  into  three 
categories: 

The  first  of  these  categories,  of  which  Spinoza  is  the  foremost  rep- 
resentative, assumes  a  "substance,"  whose  two  attributes  are  exten- 
sion (physical  series)  and  thought  (psychic  series).  However,  from 
the  viewpoint  of  the  cognitive  theory,  it  is  faulty.  Substance,  physical 
and  psychic  attributes  (in  modern  tdrms  matter,  force  and  conscious- 
ness) cannot  be  placed  side  by  side  in  this  manner.  For  direct  per- 
ception is  possible  only  in  regard  to  conscious  (psychic)  processes. 
From  a  part  of  these  we  form  conclusions  (with  some  probability) 
concerning  external  influences,  which  we  call  forces.  From  the  group- 
ing of  forces  we  construct  the  idea  of  matter,  which  needs  not  neces- 
sarily have  a  corresponding  reality.  But  there  is  still  another  diffi- 
culty in  this  theory:  It  has  to  conceive  everything  as  conscious 
whereas  we  observe  consciousness  only  in  beings  similar  to  us  and 
cannot  conceive  of  an  elementary  consciousness  without  content,  which 
is  really  connected  with  a  nervous  center.  To  be  sure,  nowhere  in 
evolution  do  we  see  a  point  where  consciousness  may  be  said  to  have 
appeared  in  man?  in  the  amoeba?  or  in  the  atom?  ^  And  the  ubiquity 
of  consciousness  is  so  readily  accepted  just  because  one  cannot  con- 
ceive of  something  principally  new  suddenly  appearing  in  evolution. 
There  is  really  no  basis  whatsoever  for  the  assumption  that  the  psychic 
and  the  physical  are  so  very  different.  We  neither  know  v>'hat  the 
psychic  nor  what  the  physical  processes  are,  and  consequently  nothing 
about  their  relationship  or  difference.  To  be  sure,  for  the  being  en- 
dowed with  feeling,  consciousness  is  something  very  special  and  the 
only  thing  of  importance.  It  is  a  matter  of  entire  indifference  to 
us  whether  the  world  exists,  the  only  thing  of  importance  being  whether 
that  which  is  conscious,  our  ego,  is  happy  or  unhappy. 

The  second  form  of  monism  starts  from  the  idea  that  all  proofs 
for  the   existence   of  an  external  world   are   false   conclusions,   and 

•Cf.  also  Loeb's  tropisms. 


PSYCHOLOGICAL  INTRODUCTION  5 

that  consequently  the  physical  world  exists  only  in  our  ideas  f Idealism; 
or,  in  so  far  as  we  conceive  it  ("esse  =  percipi").  Even  if  this  view 
could  be  carried  through  with  logical  consistency,  it  would  not  be 
able  to  acquire  a  more  general  acceptance.  For  in  the  first  place, 
it  is  incorrect  to  deny  the  outer  world  simply  because  it  is  impos- 
sible to  prove  its  existence.  Anyhow  one  is  always  forced  to  act 
as  if  it  exists.  The  philosopher  who  claims  to  believe  in  the  ex- 
istence only  of  ideas  would  have  no  reason  for  disseminating  his 
views  if  his  pupils  were  only  creations  of  his  own  imagination.  No 
matter  how  certain  it  were  that  a  rock  in  the  road  had  existence 
only  in  my  imagination,  I  would  still  have  to  go  out  of  its  way  if 
I  wished  to  avoid  something  unpleasant.  If  I  wish  to  get  rid  of 
the  feeling  of  hunger,  there  is  nothing  for  me  to  do  except  to  eat, 
whether  food  has  reality  or  not.  Practically  therefore,  idealism 
will  lead  to  an  impossibility.  Theoretically,  however,  it  leads  to 
a  conclusion  which  no  one  likes  to  accept,  to  Solipsism.  For  our  fellow 
beings  are  part  only  of  the  outer  world,  and  if  the  outer  world 
exists  only  in  my  ideas,  then  there  are  no  other  beings  beside  myself. 
/  am  not  only  the  whole  world  but  also  the  only  human  being.  This 
conclusion  is  unavoidable.  The  attempt  to  escape  solipsism  through 
the  assumption  of  an  absolute  ego  is  a  sophism.  Even  if  an  abso- 
lute ego  were  to  imagine  the  world,  it  would  not  be  my  world,  the 
world  which  I  imagine,  not  to  mention  the  fact  that  such  an  absolute 
ego  cannot  be  imagined  and  that  the  whole  assumption  is  entirely 
without  foundation. 

Much  more  common  than  the  idealistic  monism  is  the  materialistic 
monism,  the  materialistic  theory  of  cognition.  It  starts  from  the 
fact  that  we  always  see  psychic  functions  bound  to  matter,  in  par- 
ticular to  nervous  centres,  that  they  change  with  this  matter,  and 
that  the  laws  of  the  central  nervous  processes,  so  far  as  they  come 
into  consideration,  are  also  the  psychic  laws.  From  this  it  con- 
cludes that  the  psyche  is  a  function  of  the  brain.  At  present  this 
is  the  only  view  which  can  be  carried  out  theoretically  and  prac- 
tically without  contradictions,  in  the  form  of  the  so-called  hypothesis 
of  identity,  which  assumes  that  central  nervous  functions  are  ''seen 
from  within"  and  become  "conscious"  if  they  occur  in  definite  rela- 
tionships. This  view  is  almost  the  only  one  which  modern  science, 
and  in  particular  psychiatry,  takes  into  consideration,  in  fact  it  is 
even  accepted  by  those  who  theoretically  advance  another  view.  Of 
course,  this  theory,  too,  is  impossible  to  prove,  but  the  hypothesis  that 
the  psychic  functions  are  brain  functions  has  a  better  foundation 
than  most  assumptions  which  are  accepted  as  self-evident  in  the  sci- 


6  TEXTBOOK  OF  PSYCHIATRY 

ences.  But  it  is  by  no  means  necessary  as  a  basis  for  any  mental 
science,  including  psychiatry,  in  so  far  as  we  are  not  concerned  with 
studying  the  psychic  functions  in  connection  with  the  brain.  This 
theory,  too,  is  being  zealously  attacked,  primarily  on  religious  grounds. 
Perhaps  with  the  exception  of  its  earlier  periods  Christian  thought 
has  been  altogether  duahstic.  But  the  essential  content  of  the  Chris- 
tian doctrine  could  be  just  as  easily  reconciled  with  materialism  as 
with  dualism;  as  a  matter  of  fact  the  more  favored  idealism  would 
encounter  more  diflBculties.  Our  confession  of  faith  contains  the  doc- 
trine of  the  resurrection  of  the  body.  If  the  theory  of  materialism 
is  correct,  then  with  the  resurrection  of  the  body  the  soul  must  also 
eo  ipso  be  resurrected  at  the  final  judgment.  Difficulties  arise  only 
in  connection  with  secondary  doctrines  like  those  of  purgatory,  the 
existence  of  bodiless  souls,  etc.  Moreover,  partly  as  a  result  of  un- 
clear thinking  and  partly  from  rancor,  the  materialism  of  the  cogni- 
tive theory  is  usually  identified  with  ethical  materialism,  which,  re- 
gardless of  morality  and  consideration  for  other  people,  egoistically 
strives  merely  for  ''material"  goods,  by  which  is  meant  money,  posi- 
tion, good  food,  drink,  and  women.  But  the  materialism  of  the 
cognitive  theory  has  nothing  in  common  with  such  ideas  except  its 
name.  One  may  accept  any  view  of  the  cognitive  theory  and  still 
be  either  good  or  bad.  But  on  the  basis  of  the  materialistic  view, 
one  can  deduct  a  utilitarian  ethics  by  strict  logical  reasoning,  which 
is  superior  to  all  other,  which  professes  to  have  originated  from 
revelation  or  the  categorical  imperative,  or  from  other  incomprehen- 
sible eternal  laws,  and  which  at  the  same  time  can  be  fashioned  by 
every  one  according  to  his  own  desire. 

Many  modern  scientists  hold  to  the  theory  of  psycho-physical 
parallelism.  This  theory  starts  from  the  idea  that  both  series  are 
so  heterogeneous  in  principle  that  one  cannot  act  upon  the  other. 
To  explain  this  relationship  nevertheless,  Ceulincex  assumed  that  if 
the  psyche  wished  to  perform  a  physical  movement,  it  was  accom- 
plished in  each  case  by  an  interposition  of  divine  power,  and  that  every 
time  a  stimulus  strikes  the  sensory  organs  the  corresponding  sensa- 
tion is  produced  in  the  psyche  (Occasionalism) .  Leibniz,  as  is  well 
known,  held  the  view  that  these  two  series  (which  were  complicated 
by  his  theory  of  monads)  were  so  arranged  by  preestablished  harmony, 
since  the  beginning  of  creation,  that  they  run  an  entirely  uniform 
course  like  two  ideal  watches,  so  that  every  act  of  the  will  has  a  corre- 
sponding equivalent  movement,  and  every  stimulus  on  the  senses  a 
corresponding  equivalent  sensation.  But  this  theory  of  psycho-phys- 
ical parallelism  contains  one  great  error:     For  if  the  physical  series 


PSYCHOLOGICAL  INTRODUCTION  7 

cannot  react  upon  the  psychic  then  it  can  reveal  neither  its  existence 
nor  its  nature  to  our  psyche.  It  is  then  quite  useless  to  assume  that 
the  outer  world  exists,  at  any  rate  it  surely  does  not  exist  as  we 
think  we  perceive  it,  and  then  there  is  no  perception,  but  only 
hallucination. 

The  concept  of  parallelism  could  still  have  some  meaning  within 
monistic  conceptions  (Spinoza)  inasmuch  as  the  conscious  side  of 
the  substance  has  knowledge  of  the  physical  part  which  is  really  sub- 
stantially identical  with  it. 

Many  view  psycho-physical  parallelism  simply  as  a  confirmation 
of  our  ignorance  regarding  the  relationship  which  undeniably  exists 
between  the  psychic  and  physical ;  sometimes, — and  this  is  particularly 
true  of  experimental  psychology, — with  the  secondary  thought  that 
we  must  examine  what  processes  correspond  to  each  other  in  the  two 
series.  This  view  is  also  possible,  but  the  name,  which  is  otherwise 
used  quite  differently,  easily  leads  to  confusion.  Some  clinicians, 
without  realizing  it,  get  still  further  away  from  the  original  idea, 
when,  for  instance,  they  consider  hysteria  as  a  disturbance  of  the 
psycho-physical  parallelism,  because  the  psychic  reaction  to  the  ex- 
periences becomes  too  strong  or  too  weak.  Here,  of  course,  the 
physical  "parallel  processes"  in  the  brain  certainly  correspond  to  the 
psychic  phenomena.  In  this  case  therefore  the  expression  is  highly 
misleading. 

Wundt  has  assumed  a  peculiar  view  concerning  the  psycho-physical 
parallellism.  Like  many  others,  he  does  not  only  limit  the  psychic 
series  to  the  brain  functions,  but  also  makes  the  psychic  go  beyond 
the  physical,  by  assuming  that  certain  synthetic  functions  of  our 
mind  take  place  in  the  brain  without  parallel  processes.  This  is  an 
inconsistency  which  is  not  only  impossible  to  prove,  but  which,  among 
other  things,  is  opposed  by  the  fact  that  we  have  an  analogous 
synthesis  in  the  physical  sphere.  Many  reflex  processes  are  the 
result  of  a  whole  group  of  stimuli,  which  act  only  as  a  unit.  Like- 
wise the  performance  of  a  complicated  machine  is  not  equal  to  the 
simple  sum  of  the  effect  of  the  individual  constituents,  at  least  if  sum 
and  constituents  have  the  same  meaning  as  in  Wundt's  synthesis. 

In  the  dispute  between  idealism  and  materialism  one  senses  an 
uncertainty  regarding  the  value  of  reality  of  these  two  series.  But 
if  one  only  follows  up  the  thought,  this  question  can  be  very'  easily 
settled.  Only  its  own  psychic  processes  have  absolute  reality  for 
every  psyche  (it  is  not  in  their  "contents,"  i.e.  we  perceive  the 
light  or  the  rose,  but  not  the  light,  the  rose) .  If  I  feel  a  pain.  I  feel 
the  pain.     This  is  so  certain  that  it  can  only  be  expressed  tauto- 


8  TEXTBOOK  OF  PSYCHIATRY 

logically.  Since  there  are  also  hallucinated  pains,  this  pain  need  not 
necessarily  have  a  corresponding  process  in  the  aching  part  of  the 
body.  But  if  a  skeptic  does  not  wish  to  believe  that  I  feel  pain,  it 
will  be  impossible  for  me  to  prove  it.  The  psychic  series  therefore 
has  absolute,  or  better,  indisputable  reality,  but  only  for  the  psyche 
in  question.  This  reality  is  therefore  subjective.  But  for  the  ex- 
istence of  the  external  world  there  are  no  proofs.  That  the  table 
which  we  see  has  existence  is  only  an  assumption,  even  if  of  prac- 
tical necessity.  But  if  I  once  take  for  granted  the  existence  of  the 
table,  and  that  of  other  people,  and  the  external  world,  then  this 
table  can  be  shown  to  these  other  people.  Like  myself  they  can  per- 
ceive it  with  their  senses.  The  reality  of  the  physical  world  is 
therefore  uncertain  and  relative,  that  is,  it  is  not  possible  to  prove  it, 
but  on  the  other  hand,  it  is  objectively  demonstrable.^ 

The  Unconscious 

We  perform  many  trivial  actions,  such  as  stroking  our  hair,  un- 
doing a  button,  shaking  off  an  insect,  without  knowing  it.  To  a  large 
extent  these  are  neither  reflexes,  nor  subcortical  actions,  but  actions 
which  are  performed  by  the  cerebral  cortex  and  are  really  analogous 
to  conscious  functions.  Such  acts  also  presuppose  memories.  "Auto- 
matic" actions  in  hypnotic  experiments  and  in  pathological  states 
can  be  just  as  complex  in  thought  and  motility  as  any  conscious  act. 
The  hand  may  write  and  the  mouth  speak  without  the  person  hav- 
ing the  slightest  feeling  that  these  actions  originate  from  his  own 
psyche.  In  association  experiments  the  train  of  thought  often  goes 
by  way  of  ideas  which  are  not  conscious.  The  answer  to  "black" 
may  be  "star"  without  there  being  any  conscious  thought  of  "night" 
which  forms  the  connecting  link.  As  a  matter  of  fact,  the  con- 
stellations which  direct  our  thought  are  only  conscious  to  a  small 
degree,  as  a  more  detailed  analysis  shows;  we  often  make  slips  in 
speaking  which  are  based  on  unconscious  thoughts  accompanying 
it.  Only  a  small  part  of  what  our  senses  perceive  comes  into  con- 
sciousness, but  the  rest  surely  is  not  lost  to  our  psyche.  Thus,  in 
walking  we  constantly  guide  ourselves  by  perceptions  which  do 
not  become  conscious.  Many  perceptions  come  into  consciousness 
only  later  on.  Thus,  when  one  is  very  busy,  he  may  not  hear  the 
striking  of  a  clock,  but  when  the  attention  is  relaxed  it  is  so  well 

®  Psychoanalysts  also  differentiate  a  "psychic  reality."  This  term  is  mis- 
leading, for  they  refer  to  ideas  which  are  created  by  inner  needs  and  are  accepted 
and  used  as  if  they  corresponded  to  what  we  call  reality  (the  dead  child  con- 
tinues to  live,  the  fire  of  love  really  bums,  or  the  mediaeval  personal  God). 


PSYCHOLOGICAL  INTRODUCTION  9 

remembered  that  one  can  still  count  the  strokes  to  about  five.  Other' 
things  become  conscious  in  dreams  and  in  the  hypnotic  state.  Un- 
consciously a  number  of  complex  conclusions  are  drawn;  the  so-called 
intuition  is  partly  based  upon  this.  We  may  meet  a  person  and 
feel  certain  that  he  is  an  acquaintance,  but  we  arc  surprised  that  we 
do  not  evince  the  same  feelings  that  we  ordinarily  have  for  him, 
only  to  ascertain  shortly  afterwards  that  it  is  not  at  all  the  expected 
person.  Here,  besides  the  conscious  mistaken  identification,  there 
was  also  present  an  unconscious  correct  one.  The  physician  auto- 
matically puts  the  correct  key  into  the  many  different  locks  of  his 
hospital;  but  as  soon  as  he  wishes  to  do  it  consciously  there  are  diffi- 
culties. Signs  of  an  affect  are  frequently  seen  in  normal  persons,  and 
daily  in  pathological  conditions,  of  which  the  person  affected  has  no 
knowledge.  And  if  we  carefully  observe  ourselves  and  our  fellowmen, 
we  will  frequently  find  that  just  in  important  decisions  the  decisive 
elements  are  unconscious.  By  post  hypnotic  suggestions  we  can 
also  experimentally  provoke  actions,  the  motives  of  which  remain 
hidden  from  the  person  performing  them.  Hysterical  patients  may 
respond  to  perceptions  of  which  they  do  not  become  conscious. 

Everything  that  occurs  in  our  consciousness  can  therefore  also  take 
place  unconsciously.  In  this  sense  there  are  unconscious  psychic  proc- 
esses. They  have  absolutely  the  same  value  as  the  conscious  psy- 
chisms,  as  links  in  the  causal  chain  of  our  thought  and  action.  It 
is  therefore  necessary  to  include  them  among  psychic  processes, 
not  only  because  they  have  the  same  value  as  conscious  ones, 
lacking  only  conscious  quality,  but  principally,  because  psychology', 
and  particularly  psychopathology,  can  only  be  an  explanatorj-  science 
if  such  important  causes  of  the  phenomena  are  also  taken  into 
consideration. 

The  unconscious  functions  are  best  designated  as  "the  unconscious.'^ 
But  in  the  above  described  psychisms  this  does  not  imply  a  definitely 
limited  class  of  functions ;  the  real  facts,  however,  are  that  potentially 
any  function  whatsoever  can  manifest  itself  consciously  as  well  as 
unconsciously.  Neither  are  there  special  laws  for  unconscious  think- 
ing; there  are  merely  relative  differences  in  the  frequency  of  the 
different  forms  of  association. 

To  be  sure  one  may  place  into  a  special  unconscious  the  main- 
springs of  our  strivings  and  actions  which  are  also  hidden  from  our 
introspection.  This  includes  not  only  the  congenital  impulses  but 
also  the  unconsciously  acquired  paths  of  the  strivings.^" 

Such  impulses  are  particularly  striking  when  they  are  contrar\' 
"Comp.  The  Collective  Unconscious,  p.  43. 


10  TEXTBOOK  OF  PSYCHIATRY 

to  the  conscious  strivings  through  which  they  attain  the  same  patho- 
genic meaning  as  the  repressed  tendencies. 

The  unconscious  also  contains  the  paths  upon  which  the  psyche 
influences  our  secretions,  the  cardiac  vasomotor  and  other  activities, 
even  if  exceptionally  they  sometimes  become  conscious  and  are  acces- 
sible to  the  will  in  the  same  sense  as  we  move  our  limbs  consciously 
and  unconsciously.  * 

Many  authors,  notably  Freud,  Morton  Prince  and  others,  include 
among  the  unconscious  functions  also  the  "latent  memory  pictures" 
("Engrams") ."  But  these  are  principally  altogether  different  from 
what  we  have  here  described.  Latent  memory  pictures,  in  so  far  as 
we  are  concerned  here,  are  dispositions  without  actual  functions,  but 
our  unconscious  psychisms  are  actual  functions  just  as  valid  as 
those  that  are  conscious.  We  can  include  among  the  psychic  only 
those  functions  which  are  conscious,  or  may  become  conscious  under 
different  circumstances.  It  is  for  this  reason  also  that  we  do  not 
designate  the  action  of  a  machine  as  unconscious,  although  it  has  no 
consciousness. 

To  understand  the  relationship  between  conscious  and  uncon- 
scious it  is  best  to  assume  that  a  function  becomes  conscious  only 
when  it  is  in  direct  associative  connection  with  the  ego  complex;  if 
this  is  not  the  case,  then  it  follows  an  unconscious  course.  This  as- 
sumption fits  in  well  with  all  observations;  nor  does  it  run  counter 
to  the  fact  that  there  are  all  the  transitions  from  consciousness  to 
semiconsciousness  and  to  the  unconscious.  The  greater  the  number 
of  associative  connections  at  a  given  moment  between  the  ego  and 
the  psychism  (idea,  thought,  action)  the  more  conscious  and  at  the 
same  time  the  clearer  is  the  latter. 

What  we  call  "unconscious"  is  designated  by  some  as  "subcon- 
scious." Philosophers  define  the  term  unconscious  quite  differently; 
it  also  varies  in  meaning  in  different  authors. 

THE  INDIVIDUAL  PSYCHIC  FUNCTIONS 

While  taking  a  walk  I  stop  and  take  a  rest.  Then  I  see  a  well 
and  I  go  over  and  drink  some  water.  What  has  taken  place  in 
my  psyche? 

The  light  rays  which  strike  my  retina  cause  sensations,  that  is, 
I  see  certain  colors  and  lights  in  definite  spatial  arrangement.  Some 
of  these  groups  I  have  already  seen  before  in  a  corresponding  com- 
bination. As  related  units  of  a  higher  order  they  acquire  a  certain 
^'See  chapter  on  Memory. 


PSYCHOLOGICAL  INTRODUCTION  11 

independence  and  are  rendered  prominent  as  objects  (trees,  houses, 
wells),  and  from  former  experiences  I  know  that  there  is  something 
in  the  well  which  I  call  water  which  can  quench  my  thirst.  That  is, 
the  "concept"  of  the  well  with  all  its  essential  elements  has  been 
awakened  in  me,  while  the  momentary  experience  has  only  given  me  a 
number  of  color  spots.  This  awakening  of  former  similar  sensory 
complexes  by  the  new  sensation  is  a  perception.  I  have  a  sensation 
of  certain  light  arrangements  but  I  perceive  certain  objects,  I  have  a 
sensation  of  sounds  but  I  perceive  a  speech  or  the  bubbling  of  the 
spring,  I  have  a  sensation  of  an  odor,  but  I  perceive  the  scent  of  violets. 

As  I  am  thirsty,  I  have  an  "impulse"  to  drink  from  the  well.  The 
thirst  and  the  impulse  to  drink  are  evidently  also  responsible  for  the 
fact  that  the  well  was  rendered  more  prominent  than  the  numerous 
other  objects  striking  the  eye.  But  I  have  not  only  the  impulse  to 
drink,  but  I  would  also  like  to  rest  a  little  longer.  It  also  occurs 
to  me  that  the  water  might  be  infected,  that  I  will  get  a  better  drink 
in  the  next  inn,  etc.  Opposed  to  this  is  the  thought  that  I  don't 
know  how  long  I  will  have  to  walk  until  I  get  there.  The  source 
region  of  the  well  does  not  look  suspicious;  the  impulse  to  quench 
my  thirst  therefore  becomes  the  stronger  of  the  two.  I  decide  to 
take  a  drink  here,  but  to  do  it  only  after  I  have  rested  a  little  longer 
and  am  ready  to  continue  my  walk.  The  different  impulses  with 
the  ideas  accompanying  them  have  provoked  a  play  of  thought,  a 
reflection,  which  finally  had  as  its  resultant  the  decision  which  at  the 
proper  time  led  to  action. 

We  have  here  as  in  other  nervous  functions  a  centripetal  ^-  recep- 
tion of  stimuli  or  of  material,  which  we  divide  into  sensations  and 
perceptions,  and  then  an  elaboration  and  a  partial  transformation 
of  the  material  into  centrifugal  functions  (decision,  actions).  It  is 
perhaps  only  to  a  very  slight  degree,  if  at  all,  that  there  is  an 
elaboration  sufficient  to  lead  the  incoming  psychokym  ^^  by  preformed 
mechanisms  into  centrifugal  paths,  a  process  surely  not  quite  cor- 
rectly assumed  in  the  reflexes.     Here  the  elaboration  occurs  in  such 

"  I  do  not  speak  of  "psychopetal"  functions,  because  although  there  is  a  given 
"direction"  yet  both  incoming  and  outgoing  functions,  as  far  as  psychology'  is 
concerned,  take  place  within  the  psyche.  It  is  well,  however,  to  understand  by 
"center"  and  "direction"  only  symbols  and  as  little  as  possible  real  space.  On 
the  other  hand,  the  paths  between  sense  organ  and  brain,  and  between  brain 
and  muscle,  of  course,  must  be  understood  in  spatial  sense. 

^^  "Psychokym"  is  used  to  designate  psychic  processes  conceived  phj'siologi- 
cally,  namely,  that  which  is  conceived  analogous  to  a  form  of  energj-,  that 
something  which  flows  through  the  central  nen-ous  sj'stem  and  which  is  at  the 
basis  of  psychic  processes.  "Neurokym"  is  used  to  designate  the  nervous  proc- 
esses in  general. 


12  TEXTBOOK  OF  PSYCHIATRY 

a  way  that  even  new  processes  are  created.  The  perceptions  arouse 
ideas  which  combine  with  the  other  according  to  definite  norms  (Think- 
ing) and  only  the  resultant  of  these  processes  as  a  whole  determines 
the  centrifugal  action. 

Besides  these  intellectual  processes,  we  have  also  observed  the 
effects  of  two  other  functions,  which  as  qualities  are  peculiar  to 
all  psychic  functions,  or  according  to  other  views  always  accompany 
them,  namely,  memory  and  afjectivity.  In  the  process  of  percep- 
tion we  noticed  residua  of  former  experiences  which  somehow  repro- 
duce the  latter  in  content  and  in  association.  And  as  a  matter  of 
fact,  everything  psychic  leaves  behind  permanent  traces  ("Engrams") 
which  later  manifest  themselves  in  the  form  of  memories,  routine 
actions  and  the  like,  by  being  revived  ("ekphorized")  again,  and 
either  reproduce  the  same  experience,  such  as  practiced  movements 
or  hallucinations,  or  represent  it  merely  in  a  similar  manner  in  the 
form  of  an  image  after  perception. 

The  sight  of  the  well  aroused  pleasant  feelings,  likewise  the  quench- 
ing of  the  thirst;  the  idea  of  the  possibility  of  infection  aroused  un- 
pleasant ones.  Thus  every  psychic  act  is  "accompanied  by  a  feeling 
tone  (affectivity),  which  is  at  the  same  time  the  decisive  element  in 
decisions. 

We  have  also  seen  that  any  psychic  process  arouses  memory 
images  of  former  experiences,  that  through  simultaneous  occurrence, 
these  are  combined  in  such  a  manner  that  they  again  are  ekphorized 
together  and  as  a  whole,  or  as  a  unit,  that  different  ideas,  feelings 
and  strivings,  influence,  inhibit,  or  enhance  each  other,  and  finally 
are  combined  into  one  resultant.  These  different  kinds  of  combination 
among  individual  psychisms  we  call  association. 

a)     The  Centripetal  Functions 

Sensations.  The  sensations  are  the  most  elementary  psychic 
process  which  we  can  observe,  nevertheless  they  are  already  quite  com- 
plicated. Every  sensation  of  light  possesses  quality  in  two  direc- 
tions. There  is  the  quality  contrasted  with  sensations  of  other  senses 
(light,  not  sound),  and  quality  within  the  same  sensory  region  (color). 
It  further  includes  quantity,  as  the  intensity  of  the  light,  the  satura- 
tion (mixture  of  the  color  with  white) ,  and  the  local  mark  of  direction, 
as  well  as  size  and  shape. 

Perceptions.  Perceptions  arise  from  the  fact  that  sensations,  or 
groups  of  sensations,  ekphorize  memory  pictures  of  former  groups  of 
sensations  within  us.  This  produces  in  us  a  complex  of  memories 
of  sensations,  the  elements  of  which,  by  virtue  of  their  simultaneous 


PSYCHOLOGICAL  INTRODUCTION  13 

occurrence  in  former  experiences,  have  a  particularly  fine  coherence 
and  are  differentiated  from  other  groups  of  sensations.'*  In  percep- 
tion therefore  we  have  three  processes:  sensation,  memory,  and 
association.  The  hitter  should  be  taken  in  the  sense  that  the  sensa- 
tion, as  of  certain  color  spots,  or  the  bubbling  noise,  has  ekphorized  a 
concept,  like  in  the  case  of  the  well,  and  in  the  sense,  that  the  in- 
dividual sensory  engrams,  contained  in  the  concept  of  the  well,  have 
been  combined  with  each  other  before  and  now  appear  simultaneously 
as  a  unit. 

The  act  of  perception  is  not  sharply  defined.  A  statue  may  be 
perceived  merely  as  a  statue,  or  as  a  Statue  of  Shakespeare,  or  as  a 
certain  statue  of  Shakespeare.  A  word  may  be  perceived  as  a  word, 
or  as  an  English  word,  and  finally  as  a  word  with  its  meaning 
and  all  its  relations  to  a  definite  situation.  This  identification 
of  a  homogeneous  group  of  sensations  with  previously  acquired  anal- 
ogous complexes,  together  with  all  their  connections,  we  desig- 
nate as  "apperception."  It  also  embraces  the  narrower  term  of 
perception. 

b)     Concepts  and  Ideas 

Concepts.  Let  us  suppose  that  we  see  ripe  strawberries  for  the 
first  time,  either  a  number  of  them  at  the  same  time,  or  several  at 
different  times.  With  our  sight  we  have  sensations  of  certain  shades 
of  color,  certain  shapes  and  certain  proportions  of  size.  Touch  and 
kinaesthetic  senses  give  us  sensations  of  roughness,  hardness,  and 
weight,  while  the  senses  of  taste  and  smell  give  us  the  taste  and 
odor  of  the  fruit.  Among  the  berries  there  are  similarities  and  differ- 
ences. The  dissimilar  sensations  occur  only  in  seeing  one  or  a  few 
berries,  while  those  that  are  similar  appear  again  and  again.  These 
are  combined  in  the  psyche  into  a  firm  complex,  so  that  more  or 
less  vivid  memory  pictures  of  the  whole  concept  appear  whenever  a 
few  sensations  somewhat  characteristic  of  the  strawberry  are  ex- 
perienced. This  whole  structure  of  memories  of  constantly  repeated 
sensations  produced  in  us  by  the  strawberries  is  the  concept  of  the 
strawberry ,  or  the  "strawberry"  as  a  genus.  This  can  now  be  sup- 
plemented by  further  experiences,  for  instance,  by  seeing  that  the 
strawberry  grows  on  a  plant,  that  it  is  a  fruit,  that  it  has  certain 
botanical  relationships.  The  process  of  concept  formation  is  there- 
fore similar  to  that  of  type  photography. 

We  also  speak  of  the  "concept"  of  an  individual  thing  or  per- 
son, an  individual  strawberry,  an  individual  person  seen  at  different 
"See  below  "Concepts." 


14  TEXTBOOK  OF  PSYCHIATRY 

times,  at  different  distances  and  perspectives,  and  from  different  sides. 
The  residua  of  the  repeated  sensations  become  elaborated  into  a 
unified  picture  containing  only  that  which  is  common  to  all,  and  this 
forms  the  concept  of  this  certain  thing,  this  certain  person. 

On  the  other  hand,  the  concept  formation  can  also  become  com- 
plex, if  more  and  more  individual  experiences  participate  in  it.  Be- 
sides the  strawberry  we  see  many  other  things  which  grow  on  plants 
and  are  capable,  with  suitable  treatment,  to  produce  new  plants. 
Ever>'thing  that  these  things  have  in  common  again  forms  a  some- 
what firmer  engram  structure,  that  of  the  concept  "fruit." 

Concepts  of  activity  or  quality  are,  of  course,  formed  in  the  same 
manner.  "To  go"  is  composed  of  similarities  in  observing  many 
processes  together;  "blue"  emphazises  a  certain  form  of  visual  sensa- 
tions which  are  frequently  repeated.  The  highest  abstract  concepts 
are  also  formed  in  this  manner  without  anything  new  in  principle 
being  added.  One  person  rescues  his  enemy,  another  becomes  a  martyr 
for  a  good  cause,  and  a  third  does  not  steal  in  spite  of  great  tempta- 
tion. All  these  occurrences  have  something  in  common  which  lies 
in  our  feeling  tone,  as  well  as  in  the  significance  that  these  acts  or 
omissions  have  for  the  community.  What  they  have  in  common,  if 
rendered  prominent,  gives  us  the  concept  of  "virtue."  In  ourselves 
and  in  the  external  world  we  observe  that  certain  events  always 
follow  upon  certain  others.  What  is  common  to  them  we  call  "cause" 
and  "effect"  or  in  connection  with  the  other  relations  of  the  things 
and  events  among  themselves,  "causal  relationship." 

A  very  important  task  which  must  partly  precede  and  partly  ac- 
company concept  formation  is  the  selection  of  the  material.  We  do 
not  form  a  picture  of  a  tree  with  the  different  perspectives  of  its 
location  and  the  other  simultaneous  experiences  which  were  present 
when  we  saw  it,  nor  do  we  see  it  with  all  its  different  fronts,  but 
only  the  tree  in  particular  in  an  aspect  which  is  especially  suitable 
to  our  view.  Everything  else  that  was  part  of  the  experience  in  form- 
ing the  concept  tree  is  eliminated  in  the  concept-formation.  The  par- 
ticular associations  which  were  necessarily  formed  by  the  coincidence 
of  the  experience,  and  the  existence  of  which  can  be  shown  by 
occasional  tests,  are  inhibited.  This  is  only  a  slight  indication  of  the 
enormous  work  our  psyche  must  perform  in  putting  together  and  sep- 
arating the  individual  engrams,  even  in  the  simplest  functions.  As 
a  rule,  only  the  positive  process,  the  putting  together,  is  noticed.  The 
inhibition,  or  the  elimination,  is  underestimated  or  even  entirely 
ignored.^^ 

''See  Oligophrenia. 


PSYCHOLOGTCAT.  INTRODUCTION  15 

Simultaneously  with  the  perception  of  a  thing  or  a  process  we 
very  frequently  also  hear  the  word  which  designates  the  thing.  This, 
then,  must  also  be  combined  with  the  concept  in  a  manner  similar 
to  its  individual  components,  though  the  association  is  distinctly  not 
as  close.  In  every  person  who  knows  the  fruit,  the  word  "straw- 
berry" also  evokes  the  concept  of  the  strawberry.  Language,  how- 
ever, is  of  still  greater  importance  for  concept  formation,  inasmuch 
as  with  the  help  of  the  word  it  transmits  to  others  the  definitions 
of  concepts  once  formed.  The  individual  may  easily  come  to  form 
the  concept  "tree,"  but  without  the  cooperation  of  former  generations 
it  would  be  somewhat  more  difficult  to  form  that  of  "plant."  The 
different  language  groups  therefore  have  different  concepts.  The 
French  "manger'''  embraces  the  German  "essen"  and  "fressen."  The 
English  "fish"  is  a  much  wider  concept  than  the  German  "Fisch." 
The  German  "Brunnen"  resolves  itself  in  French  into  "fontaine"  and 
then  "puits."  However,  the  importance  of  language  for  concept  for- 
mation has  also  been  overestimated.  The  child  was  thought  to  be 
unable  to  differentiate  men  from  each  other  as  long  as  it  called 
each  one  "papa,"  but  it  can  be  easily  shown  that  this  is  usually 
wrong.  Likewise,  the  extent  of  a  person's  vocabulary  was  thought 
to  indicate  the  number  of  his  concepts  and  consequently  the  con- 
cepts of  an  English  laborer  of  the  lowest  grade  were  supposed  to 
number  only  a  few  hundred.  But  any  idiot,  if  he  is  only  able  to 
express  concepts,  and  any  dog  have  many  more  than  that.  Untrained 
deaf  mutes  form  not  only  many  concrete  but  also  abstract  concepts. 
There  are  also  people  who  are  as  rich  in  words  as  poor  in  concepts 
(higher  forms  of  dementia),  or  poor  in  words  and  rich  in  con- 
cepts. It  was  also  asserted  that  one  can  only  think  in  words.  The 
actual  facts  are  that  in  ordinary  thought  one  uses  abbreviated  sym- 
bols instead  of  concepts.  Words  are  frequently  used  as  such  symbols, 
but  there  are  also  very  different  kinds  of  symbols.  Different  in- 
dividuals prefer  different  ones.  Thus  for  numbers  some  use  the 
word,  others  the  figure,  still  others  conceive  them  in  form  of  a 
colored  spot  or  in  regard  to  their  mere  position  in  a  numerically 
schematized  scale,  etc. 

Concepts  are  not  fixed;  they  are  easily  supplemented  or  trans- 
formed by  new  experiences.  The  concept  "God"  is  not  only  differ- 
ent in  the  savage  and  the  civilized  person,  but  also  in  the  child  and 
the  adult,  the  educated  and  the  uneducated.  The  concept  of  elec- 
tricity is  changed  when  one  begins  to  study  it  through  higher 
mathematics,  etc. 

In  every  concept  formation,  even  the  simplest,  we  see  the  activity 


16  TEXTBOOK  OF  PSYCHIATRY 

of  the  process  of  abstraction,  that  is,  certain  classes  of  sensations  and 
memory  pictures  are  pushed  aside,  and  others  are  rendered 
prominent. 

Abstraction  does  not  represent  a  special  or  even  "higher"  faculty, 
but  it  is  inherent  in  the  nature  of  the  nervous  centre  and  hence  be- 
longs to  psychic  activity.  For  in  both  of  these  activities  there  are 
no  identical  experiences,  but  only  similar  ones.  One  must,  therefore, 
not  take  too  literally  the  statement  in  physiology  that  the  same 
reactions  follow  the  "same"  stimuli.  In  reality,  the  nervous  centres 
respond  to  similar  processes  in  the  same  manner;  unessential  differ- 
ences do  not  noticeably  influence  the  reaction,  that  is,  the  centre  or 
the  reaction  makes  use  of  the  process  of  abstraction.  If  memory 
images  with  associatively  connected  processes,  such  as  thoughts  or 
actions,  take  the  place  of  preformed  or  reflex  mechanisms,  then  the 
abstraction  from  these  differences  becomes  more  diversified  but  not 
different  in  principle.  This  is  already  the  case  in  perception.  The 
infant  sees  its  mother  at  different  distances,  in  different  projec- 
tions and  different  clothes,  and  yet  recognizes  her  as  the  same  being, 
by  abstracting  from  these  differences.  It  is  also  the  same  kind  of 
abstraction  as  in  concept  formation,  when  in  his  general  perception 
the  child  raises  its  mother  from  the  environment.  Although  the 
infant  never  sees  the  mother  alone,  he  always  observes  her  together 
with  the  room,  yet  he  is  able  to  abstract  and  emphasize  the  mother 
concept.  That  this  is  an  important  function  can  be  seen  in  those 
cases  where  it  fails.  Children  frequently  behave  very  differently 
toward  the  same  persons  in  a  different  environment.  In  the  case 
of  cats,  one  regularly  observes  that-  they  act  as  strangers  outside  of 
the  house  to  persons  of  their  home. 

That  the  abstraction  does  not  merely  take  away  from  a  number  of 
engram  groups  some  components  and  combines  the  rest  into  one 
sum  but  forms  thereby  a  new  psychic  structure  is  self  evident 
and  is  in  no  way  peculiar  to  the  psyche.  Thus  a  clock  work  is 
as  little  the  mere  sum  of  its  little  wheels  as  a  human  being 
is  the  sum  of  his  cells  and  molecules  ("mere  sum"  is  precisely 
an  abstraction,  which  exists  as  little  in  reality  as  the  "sum" 
two). 

Ideas.  Everything  that  has  been  perceived  by  the  senses,  such  as 
qualities,  things  and  processes,  is  imagined  as  an  ekphorized  memory 
picture.  In  addition,  the  ideas  contain  also  psychic  structures  which 
have  never  been  perceived  by  the  senses.  Among  these  we  have  all 
possible  combinations  of  sensory  images,  phantasies,  wishes  and  pos- 
sibilities, as  well  as  the   abstractions  and  their  combinations  with 


PSYCHOLOGICAL  INTRODUCTION  17 

ideas;  indeed,  it  comprises  every  tiling  in  so  far  as  it  can  become  actual 
in  time  by  ekphorization  and  not  by  sense  perception.^'^ 

c)     The  Associations.     Thought. 

Combinations  of  Psychisms  We  Call  Associations. 

We  see  tliem  in  different  forms;  they  may  also  combine  with 
each  other  and  cannot  really  be  sharply  separated  from  one  another. 

(1)  Two  synchronous  functions  may  modify,  enhance  or  inhibit 
each  other.  The  perception  of  the  road  as  well  as  the  obstacles 
direct  our  steps.  A  moral  reflection  inhibits  a  reproachable  act. 
Two  motives  acting  in  the  same  direction  promote  the  reaction. 
Physical  functions  such  as  reflexes  may  be  influenced  in  all  three 
directions  by  accidental  secondary  stimuli. 

(2)  Simultaneous  or  successive  experiences  are  connected  with 
each  other,  in  so  far  as  they  have  a  tendency  to  appear  together  in 
memory,  or  in  so  far  as  the  revival  of  one  of  these  experiences  recalls 
the  others.  We  may  add  to  this  the  fact  that  our  ideas  and  concepts, 
with  many  or  all  of  their  components,  simultaneously  appear  in 
memory  or  thought,  or  follow  in  immediate  succession.  If  we  hear 
the  word  rose  or  think  of  a  rose,  we  also  have  a  more  or  less  clear 
idea  of  the  individual  psychisms  red,  beautiful,  fragrant,  all  of  which 
form  the  general  concept  of  flower. 

(3)  One  idea  generates  another.  We  think  of  roses,  and  this 
in  turn  suggests  a  verse  we  learned  about  tulips  and  carnations.  We 
set  out  to  write  our  name,  whereupon  follow  the  different  move- 
ments in  the  accustomed  and  successive  order.  This  also  explains  why 
a  certain  action  is  performed  after  a  given  signal.  In  the  psycho- 
logical selection  experiment  we  perform  the  required  reactions,  thus 
to  the  bell  signal  we  react  with  the  right  hand,  to  the  optic  signal 
with  the  left.  This  function  already  resembles  much  the  reflex  process 
which  is  also  no  simple  transition  of  the  sensory  stimuli  to  the  motor 
apparatus,  but  a  setting  in  motion,  or  generating  the  function  of  a 
performed  mechanism. 

(4)  The  forms  mentioned  may  occur  in  any  combination.  In 
the  sense  of  the  progressive  association  (Form  3),  the  perception  of 
an  apple  generates  in  the  child  the  impulse  to  eat  it,  but  also  the 
memory  picture  of  the  thrashing  formerly  provoked  by  stealing  it, 
and  these  later  inhibit  the  acquisition  impulse  as  a  simultaneous 
function   (Form  1). 

Ordinarily,  however,  we  do  not  think  of  all  these  forms  but  only 
of  the  following  phenomena: 

"For  the  differences  between  ideas  and  perceptions,  see  p.  66. 


18  TEXTBOOK  OF  PSYCHIATRY 

(1)  Through  temporal  connections  in  experience,  associations  are 
created  in  the  corresponding  engrams  (associations  are  formed). 
(2)  These  connections  remain  in  existence  with  the  engrams  of  the 
experiences  (engrams  are  associated).  (3)  A  new  event  may  ekphorize 
the  engrams  of  memory  images  which  (a)  have  somehow  become 
connected  at  its  origin  or  which  (6)  refer  to  the  same  experiences, 
or  which  (c)  refer  to  similar  experiences.  In  the  same  manner  a 
whole  idea  is  likewise  associated  to  a  former  one.  In  the  same 
manner  as  in  simple  concepts  whole  ideas  form  associations  among 
one  another. 

Association  is  a  state  so  far  as  engrams  are  connected  with  one 
another.  But  it  is  also  a  process,  through  the  connection  of  simul- 
taneous experiences,  through  the  generation  of  one  idea  by  another, 
as  in  thought,  and  above  all  through  the  influence  of  one  psychism 
upon  another. 

Associations  in  the  sense  of  permanent  connections  originate  when 
several  psychisms  take  place  simultaneously  or  in  immediate  suc- 
cession, as  can  be  seen  in  the  act  of  perceiving  the  association  of 
lightning  and  thunder.  We  must  assume  that  everything  simultane- 
ous and  successive  is  connected  in  the  psyche,  not  only  because 
such  functions  very  frequently  influence  each  other,  but  because  they 
appear  connected  in  memory,  as  shown  by  every  day  experiments. 
If  something  has  eluded  us,  we  can  frequently  recall  it,  by  going 
to  the  place  where  the  thought  or  experience  took  place,  indeed, 
even  if  there  is  no  logical  connection  between  the  place  and  the  for- 
gotten content  of  the  ideas.  And  yet  the  associations  accessible  to 
us  evince  a  certain  selection.  Primarily  we  recall  only  experiences 
which  in  themselves  or  through  their  connections  have  a  certain  im- 
portance for  us.  In  reference  to  the  capacity  to  ekphorize  there  are 
thus  important  differences  in  the  associations,  and  perhaps  also  in 
the  elaboration  of  memory  images.  Unfortunately  we  cannot  enter 
here  into  the  investigation  of  these  differences;  at  any  rate  affective 
mechanisms  cooperate  in  them. 

Moreover,  as  seen  in  every  other  function,  there  is  also  some- 
thing negative  in  the  formation  of  associations.  If  we  have  once 
been  accustomed  to  write  a  letter  of  the  alphabet  in  a  certain  man- 
ner, there  will  be  a  tendency  always  to  write  it  the  same  way,  even 
if  we  did  not  write  for  a  long  time.  But  if  we  have  later  acquired 
a  different  form  of  writing,  then  there  is  difficulty  in  reproducing 
the  earlier  ones,  even  if  we  think  of  it  in  due  time.  The  present 
medical  training  does  not  make  psychological  thinking  difficult  because 


PSYCHOLOGICAL  INTRODUCTION  19 

it  ignores  it,  but  mainly  because  it  forms  associations  in  other  direc- 
tions and  thereby  virtually  inhibits  psychological  thinking. 

If  we  consider  the  associations  as  a  process  of  memory,  we  see 
that  what  has  been  experienced  simultaneously  or  in  immediate  suc- 
cession is  ekphorized  with  relative  frequency.  Furthermore,  for  evi- 
dent reasons,  this  is  also  true  of  similar  and  analogous  experiences.^^ 
The  child  having  burned  itself  by  a  candle,  is  afraid  of  all  fires. 

Most  associations,  particularly  those  obtained  by  simultaneous- 
ness,  may  take  either  the  course  a — b  or  b — a.  In  related  individual 
experiences,  as  in  the  details  of  a  lawsuit,  direction  plays  no  part 
whatever,  as  a  single  component  associates  the  main  concept,  which 
connects  them  all  and  from  it  other  details  can  result  in  any  series 
of  succession. 

But  under  certain  conditions  direction  is  not  a  matter  of  indiffer- 
ence. This  is  particularly  true  of  associations  which  are  important 
only  as  they  follow  each  other.  No  matter  how  fluently  we  can 
recite  the  alphabet  or  a  verse,  to  say  it  in  reverse  order  can  at  first 
be  done  only  with  difficulty.  Many  associations  of  motion  we  can 
never  reverse.  For  even  if  we  are  able  to  draw  a  letter,  by  start- 
ing from  the  front  or  back,  we  have  two  different  motions  in  which 
the  muscles  do  not  simply  contract  in  reverse  order.  But  even  as- 
sociations formed  by  simultaneousness  may  obtain  a  one  sided  direc- 
tion through  practice.  Most  people  who  can  read  the  printed  Gothic 
letters  have  not  necessarily  the  capacity  to  form  an  image  of  them 
by  hearing  them.  For  reasons  easily  understood,  the  direction  from 
the  special  to  the  general  has  a  relative  preference  over,  and  against 
the  reverse.  A  name  very  easily  arouses  the  idea  of  the  person 
designated  by  it,  while  it  frequently  happens  that  the  idea  does  not 
call  forth  the  name.  The  latter  element  is  of  importance  in  patho- 
logical disturbances  of  memory. 

Logical  thinking  is  at  first  a  repetition,  an  ekphoria  of  associative 
connections,  that  were  once  experienced,  or  of  similar  or  analogous 
connections. 

Every  time  we  dig  around  a  tree  we  see  the  roots.  An  association 
is  therefore  formed  between  the  idea  of  the  tree  and  the  root.  If  we 
see  a  tree  and  the  concept  root  comes  into  consideration,  it  is 
associated  with  the  tree,  and  what  is  more,  it  has  an  added  feel- 
ing of  belonging  together.     In  the   subsequent   abstracted   laws   of 

"  Similar  or  analogous  experiences  have  in  common  partial  psychisms.  Fur- 
thermore, the  sensibility  of  the  psyche  and  possibly  of  the  central  ner\-ous  system 
for  differences  is  limited.  Whatever  has  differences  below  a  certain  limit  appears 
and  acts  as  being  identical. 


20  TEXTBOOK  OF  PSYCHIATRY 

logic  we  express  it  as  follows:  Every  tree  has  roots;  this  is  a  tree, 
therefore  it  has  roots.  But  we  only  think  in  this  way  in  exceptional 
circumstances,  when  the  correctness  of  the  inference  is  questioned, 
as  in  "proving"  something.  The  millions  of  inferences,  which  are 
daily  made  in  thought  and  action,  are  accomplished  in  a  much  simpler 
way.  If  one  wishes  to  percuss  a  person's  heart,  one  does  not  say: 
Every  man's  heart  is  on  the  left  side;  this  is  a  man,  therefore  his 
heart  is  on  the  left  side,  but  one  simply  associates  the  customary 
place  with  the  idea,  to  percuss  the  patient's  heart. 

Conclusions,  therefore,  like  thought  in  general,  are  repetitions  of 
identical  or  analogous  associations  as  we  see  them  in  life. 

One  can  prove  the  Pythagorean  proposition  through  four  experi- 
ences which  every  person  has  gone  through;  from  two  special  ex- 
periences (hypothetical  lines  drawn  for  this  purpose)  and  from  nine 
analogous  associations,  wherein,  however,  generally  existing  concepts 
such  as  triangle,  right  angle,  parallels,  and  multiplication  are  assumed, 
and  hence  not  enumerated. 

Causal  thinking  is  only  an  analogy  of  the  regular  sequence  of  two 
ordinary  events,  or  of  the  general  sequence  of  two  unusual  events. 
When  it  gets  warm,  the  snow  melts.  An  otherwise  incurable  dis- 
ease is  cured  as  a  result  of  a  new  remedy .^^  Of  course,  the  terms 
"regular  sequence"  and  "unusual  event"  are  very  indefinite.  Thus, 
for  the  savage,  many  things  are  propter  hoc  which  for  us  are  only 
post  hoc.  Moreover,  it  must  be  determined  through  further  experi- 
ence, whether  one  event  depends  directly  upon  the  other,  or  whether 
both  can  be  traced  back  to  the  same  cause.  The  rotation  of  the  earth 
is  the  common  cause  of  both  day  and  night,  although  for  children 
and  in  myths,  day  arises  from  the  night.  A  falling  barometer  and 
rain  have  a  common  cause.  Nevertheless  we  frequently  see  a  desire 
to  smash  the  falling  barometer  in  order  to  force  good  weather.  But 
causal  concepts  contain  also  inner  experiences.  We  ourselves  are  very 
often  a  link  in  the  causal  chain.  Through  our  own  actions  we  can 
set  up  causes  and  therefore  effects.  We  even  permit  our  actions  to 
be  influenced  by  these  considerations.  We  see  causes  outside  of  us  and 
motives  within  us.  But  these  two  relationships  can  only  be  differ- 
entiated by  the  viewpoint  from  which  they  are  seen,  and  possibly 
through  the  greater  complication  of  the  apparent  motives  as  compared 
with  the  apparent  causes. 

"As  a  matter  of  fact  no  occurrence  has  only  o?!e  cause.  The  main  difficulty 
in  causal  investigation  lies  precisely  in  the  manifold  preconceptions  connected 
with  every  single  occurrence.  However,  in  psj-chological  reflection  it  is  not 
necessary  to  solve  the  causal  concept  in  the  sum  of  conditions,  as  useful  as  it 
would  be  in  medicine  to  apply  it  \vith  greater  clearness  than  is  usually  the  case. 


PSYCHOLOGICAL  INTRODUCTION  21 

Many  persons  have  recently  attached  great  importance  to  the  dif- 
ferentiation between  "causal"  and  "final"  thinking.  There  is  no 
difference  as  regards  logical  forms.  In  final  thinking  determinants 
referring  to  the  future  are  taken  into  consideration,  as  in  the  case 
of  calculating  in  advance  an  eclipse  of  the  sun.  But  there  is  a 
certain  difference  in  the  goal  of  thinking;  the  final  operation  deter- 
mines our  action,  while  in  causal  thinking  the  explanation  obtained 
satisfies  our  need.  To  be  sure,  the  final  function  is  the  original  and 
usual  one.  The  causal  function  acquires  greater  importance  only  in 
the  civilized  person,  who  satisfies  his  growing  need  for  theoretical  ex- 
planation and  who,  at  the  same  time,  has  learned  to  value  the  great 
advantage  offered  him  by  a  causal  understanding  of  the  associations 
of  future  achievements. 

Judgment  consists  in  a  repetition  of  associations  acquired  through 
experience.  "Snow  is  white,"  "Kant  was  a  great  man,"  are  expres- 
sions of  direct  and  indirect  experiences.  But  it  is  important  to  note 
that  the  word  "judgment"  signifies  two  things.  In  logic,  judgment  is 
"the  form  in  which  cognitions  are  thought  and  expressed."  But  if  we 
speak  in  psychiatry  and  jurisprudence  of  the  capacity  to  judge,  we 
mean  the  ability  to  form  judgments,  that  is,  the  capacity  to  draw 
correct  conclusions  from  the  material  acquired  by  experience. 

In  tracing  back  the  individual  thought  processes  to  external  as- 
sociations we  have,  of  course,  not  completely  explained  "thought." 
When  the  concept  "tree"  is  awakened  in  us,  we  do  not  always  associ- 
ate its  roots  with  it.  We  only  do  this  when  this  direction  is  de- 
termined by  a  certain  constellation,  as  in  observing  that  the  wind  may 
uproot  the  tree,  or  by  the  trend  of  thought,  as  when  we  think  about 
the  nutrition  of  the  tree.  For  every  single  idea  has  countless  others 
which  are  associatively  connected  with  it.  Which  of  these  paths  is 
followed  in  a  concrete  case  depends  upon  broader  determinants,  among 
which  the  trend  of  thought  and  the  constellation  are  most  important. 

The  aim  of  thought  is  not  something  simple  but  a  whole  hierarchy 
of  a  trend  of  ideas  systematically  arranged.  If  I  wish  to  write  now 
about  associations,  I  must  constantly  have  this  aim  before  me  more 
or  less  consciously,  but  besides  this  I  must  also  view  the  plan  as  a 
whole,  as  far  as  I  have  worked  it  out,  the  basic  thought  of  a  chapter 
and  of  a  sentence,  what  I  have  said  before,  etc. 

Even  in  such  mental  trends  which  are  seemingly  xevy  much  con- 
nected, the  momentary  and  general  constellation  plays  a  noticeable 
part.  It  was  momentary  constellation  which  suggested  to  me  the 
example  just  used  in  illustration.  The  course  of  ideas  is  not  only 
determined  by  immediate,  but  also  by  former  experiences.     The  con- 


22  TEXTBOOK  OF  PSYCHIATRY 

stellation  also  becomes  an  essential  factor  in  loose  or  aimless  think- 
ing. A  person  who  is  hungry,  or  vice  versa  one  whose  stomach  is 
overfilled,  starting  from  any  idea  at  all,  is  much  more  likely  to  hit 
upon  an  association  or  an  idea  concerning  food  (dream!).  A  person 
who  is  just  coming  from  a  lecture  on  chemistry  and  hears  of  "water" 
will  not  easily  think  of  water  in  connection  with  scenery  or  with 
commercial  uses. 

Besides  the  positive  effect,  mental  trends  and  constellations  have 
also  a  pronounced  negative  effect.  Every  psychic  process  like  every 
other  central  nervous  process,  not  only  promotes  the  minor  selection 
of  like-minded  functions,  but  it  also  inhibits  the  infinite  number  of 
other  psychisms.  The  development  of  thinking  is  therefore  also 
in  this 'respect  entirely  parallel  to  that  of  motility,  which  must  not 
only  learn  to  contract  the  necessary  muscles  in  proper  sequence, 
but  must  also  learn  not  to  put  tension  in  all  the  others. 

If  we  free  the  associations  as  far  as  possible  from  ideas  of  a 
special  trend  by  instructing  a  test  person  to  repeat  as  quickly  as 
possible  the  first  word  flashing  through  his  mind  when  a  word  is  called 
out  to  him,  we  then  find  that  the  simple  associations  of  experience 
and  constellation  come  to  the  surface  very  clearly.  We  thus  find 
associations  of  spatial  and  temporal  contiguity,  of  similarity  and  con- 
trast, of  coordination  and  subordination,  and  of  conceptual  and  sound 
similarities.  Some  pretend  to  see  in  the  grouping  of  these  different 
kinds  of  associations  the  "laws  of  association."  But  from  what  has 
been  said  above,  it  is  self-evident  that  they  are  only  a  fractional 
part  of  the  determinants  of  our  natural  thinking. 

The  principal  trend  of  thought  is  determined  by  the  impulses  and 
the  affects.  We  wish  to  reach  a  definite  aim.  But  even  in  the  in- 
dividual elements  of  thought  we  can  see  the  influence  of  affective 
needs.  It  accounts  for  daily  disturbances  and  even  direct  falsifica- 
tions of  logic,  which  manifest  themselves  to  a  slight  degree  in  normal 
persons  and  to  a  much  greater  extent  in  the  insane.^^ 

The  material  taken  up  forms  new  combinations  in  phantasy, 
whereby  different  degrees  of  detachment  from  experience  become 
possible.  The  inventor  has  set  for  himself  new  aims  which  he  en- 
deavors to  attain  by  analogy  to  the  familiar.  The  poet  assumes 
greater  freedom  of  movement,  and  in  fairy  tales  and  in  mythology  he 
is  thus  able  to  put  himself  in  an  attitude  contradictory  to  reality, 
to  be  sure,  in  a  senseful  manner.^" 

The  associations  are  not  peculiar  to  the  psyche  alone,  but  they 

"See  affectivity;  delusions. 
^°  Cf.  Dereistic  thinking,  p.  45. 


PSYCHOLOGICAL  INTRODUCTION  23 

can  be  experimentally  demonstrated  in  the  other  central  nervous  proc- 
esses, in  all  their  qualities  except  the  quality  of  consciousness.  It 
is  true  that  Pawiow's  "association  reflexes"  (conditioned  reflexes)  go 
via  the  cerebral  cortex,  which  alone  is  capable  of  such  plastic  func- 
tions to  a  high  degree,  but  this  does  not  mean  that  they  must  go  via 
the  psyche,  and  particularly  beyond  the  conscious  psyche. 

The  mechanism  of  association,  the  possibility  that  parallel  psy- 
chisms  may  or  may  not  influence  each  other,  and  that  of  the  infinite 
number  of  possible  paths  a  particular  one  is  taken  by  choice,  can 
best  be  understood  by  comparing  it  with  the  switches  in  an  electrical 
plant.  These  switches  may  connect  different  machines  with  one  an- 
other or  let  them  run  independently  of  each  other;  they  can  switch 
them  on  or  off.  The  constellation  determined  in  our  example  by  the 
lecture  on  chemistry  decreases  something,  which  in  the  electrical 
plant  would  correspond  to  the  resistance  in  the  direction  of  "chem- 
istry," and  it  increases  the  resistance  in  other  paths.  That  is  the 
reason  why  the  idea  "water"  evokes  associations  of  chemical  ideas 
of  this  concept  rather  than  others.  The  comparison  with  electrical 
switches  also  makes  it  possible  for  us  to  understand  a  number  of 
other  phenomena,  such  as  flight  of  ideas,  schizophrenic  disturbance 
of  association,  hypnotic  phenomena,  the  existence  of  different  per- 
sonalities in  the  same  psyche  either  simultaneously  or  side  by  side, 
the  phenomena  of  the  unconscious,  and  a  number  of  pathological 
symptoms  which  are  either  denied  or  reluctantly  admitted.  One  must 
be  careful,  however,  not  to  connect  the  concept  of  association  and 
switching  with  any  idea  of  cerebral  localization.  According  to  our 
present  day  knowledge  it  is  quite  possible  that  the  individual  con- 
cepts are  partially  (or  wholly)  "localized"  in  the  same  anatomical 
structure. 

d)     The  Intelligence 

The  foundations  of  intelligence  lie  in  the  process  of  association. 
It  is  a  complex  of  many  functions  which  can  be  differently  developed 
in  every  individual.  There  is  no  uniform  intelligence.  It  would 
be  a  praiseworthy  task  to  elucidate  once  for  all  the  whole  concept  of 
intelligence.  Besides  the  faculty  of  intelligence,  it  would  be  im- 
portant to  abstract  correctly  the  following  points:  (1)  the  capacity 
to  understand  what  is  perceived  or  explained  by  others,  (2)  the  ca- 
pacity to  be  able  to  act  in  such  a  manner  as  to  achieve  what  one 
is  striving  for,  and  (3)  the  capacity  to  make  correct  combinations 
of  new  material  (logical  power  and  phantasy). 

All  these  achievements  are  primarily  dependent  upon  the  numher 


24  TEXTBOOK  OF  PSYCHIATRY 

of  possible  associations.  The  greater  the  number  of  stones  at  our 
disposal,  the  greater  the  number  of  ideas  and  the  finer  the  shades 
that  we  can  express  in  the  mosaic  of  our  thinking.  In  the  animal 
series,  or  from  the  idiot  to  the  genius,  the  scale  of  intelligence  de- 
pends principally  upon  an  increase  in  the  possibilities  of  association. 
Of  secondary  importance  we  consider  the  speed  and  ease  in  the  flow 
of  associations.  For  the  scholar  in  his  study  it  may  not  be  very 
important  how  much  time  he  takes  for  his  reflections.  But  a  per- 
son in  active  life  must  be  able  to  survey  a  situation  rapidly  and 
to  draw  the  conclusions  necessary  for  action.  Intelligent  achievement 
also  includes  the  proper  selection  of  the  material  to  be  associated.  I 
only  enumerate  this  in  the  third  place  because  this  function  is  com- 
paratively satisfactory  to  the  average  person.  It  is  relatively  rare 
to  find  many  irrelevant  associations;  one  observes  this  mostly  in 
oligophrenics  lacking  mental  clearness  whom  we  shall  discuss  later. 
To  select  the  appropriate  material  it  is  necessary  to  differentiate 
between  the  important  and  the  unimportant.  This  is  a  complicated 
function  and  depends  on  the  survey  of  the  whole  subject  and  there- 
fore, in  the  final  analysis,  again  on  the  number  of  associations.  In 
order  to  make  new  combinations  and  not  merely  to  follow  in  the  old 
grooves,  there  must  be  a  certain  capacity  to  split  up  the  associa- 
tions into  their  components,^^  but  one  also  needs  a  special  activity 
of  the  will  and  thought  in  the  direction  of  controlling  the  circumstances. 

The  greater  the  intelligence,  the  more  use  is  made  of  elaborated 
thought  material.  The  intelligent  person  makes  far  less  use  of  con- 
cepts which  are  still  closely  related  to  perceptions  than  of  inferences 
drawn  from  them,  and  often  enough  he  is  altogether  unable  to 
reproduce  the  original  experiences.  He  follows  his  judgment  of  a 
person  without  thinking  how  he  came  to  this  judgment.  He  also 
thinks  his  concepts  with  their  relationships.  On  the  other  hand, 
he  also  resorts  to  short  cuts;  this  is  partly  accomplished  through 
the  arrangement  of  details  into  a  uniform  main  concept  which  is 
already  a  short  cut,  and  partly  by  changing  complex  ideas  into 
symbols,  which  are  not  only  used  in  intercourse  with  others  but 
also  in  thinking  (e.g.  mathematical  signs  like  tt,  sin,  etc.). 

A  schoolgirl  asks  her  mother  for  some  money  for  a  poor  friend, 
so  that  the  latter  may  join  in  a  school  picnic.  The  mother  refuses, 
since  she  has  no  money  herself.  The  girl  observes  that  her  playmate 
frequently  earns  a  few  nickels  for  running  errands.  She  now  conveys 
to  her  the  idea  that  all  she  has  to  do,  in  order  to  get  enough  money 
for  the  picnic,  is  to  save  this  money  instead  of  spending  it,  and  for 
"  Cf.  Concept  formation,  p.  14,  and  the  oligophrenias. 


PSYCHOLOGICAL  INTRODUCTION  25 

this  purpose  she  gives  her  a  small,  improvised,  savings  bank.  Besides 
she  keeps  on  inquiring  how  much  money  the  child  has  earned  and 
what  she  has  done  with  it.    This  proved  to  be  quite  successful. 

Here  we  deal,  in  the  first  place,  with  a  characterological  function 
on  which  all  that  follows  is  dependent.  The  girl  was  not  satisfied 
with  her  mother's  answer  and  tried  to  find  another  solution.  But 
pure  intelligence  also  had  a  share  in  this  first  step.  The  girl  had 
to  recognize  the  possibility  of  providing  help,  before  she  found  the 
solution,  while  a  feeble-minded  person  would  have  faced  an  impos- 
sibility from  the  very  beginning.  The  next  step  was  seemingly  very 
simple,  but  only  seemingly,  for  often  enough  it  fails  in  reality,  in 
spite  of  the  fact  that  it  is  so  frequently  drilled  in;  we  refer  to  the 
application  of  the  thought  that  twenty  nickels  make  a  dollar,  that 
is,  that  one  has  to  save  only  twenty  nickels  in  order  to  have  a  dollar. 
To  seek  a  way  out  of  a  difficulty,  in  spite  of  the  fact  that  the  nearest 
solution  is  impossible  and  the  application  of  this  mathematical  prin- 
ciple i§  what  differentiates  civilized  people  from  those  that  remain 
primitive.  After  giving  the  advice  to  save,  many  a  sage  would  have 
considered  the  matter  settled.  But  here  we  have  besides,  the  im- 
portant idea  of  the  small  savings  bank.  This  required  the  "feeling" 
which  many  moralists  lack,  and  which  is  of  course,  a  purely  in- 
tellectual process,  that  mere  advice  was  not  sufficient,  that  is,  it 
requires  a  complex  of  associations  regarding  the  fickleness  of  her 
friend  and  the  desire  to  make  it  harmless.  For  this  purpose  a  means 
was  invented,  with  the  help  of  imagination,  to  interest  the  spend- 
thrift in  another  direction.  That  this  solution  was  sought  and  found, 
of  course  again  presupposes  the  possession  of  a  great  number  of  ideas 
regarding  the  psychology  of  her  friend,  and,  in  the  long  run,  of  people 
in  general.  Furthermore,  there  was  the  capacity  to  utilize  all  these 
ideas  at  the  proper  moment,  and  at  the  same  time  to  sift  the  experi- 
ences into  what  is  important  and  w4iat  is  unimportant  for  this  par- 
ticular case.  This  latter  selection  requires  among  other  things  the 
constant  presence  of  the  psychological  ideas  about  the  motives  of 
action,  for  it  is  with  the  guidance  of  these  ideas  that  the  sifting  must 
be  done.  Intellectual  as  welli  as  characterological  functions  are 
involved  in  the  subsequent  supervision  of  saving  and  in  the  dctach- 
ment  from  the  usual  associations.  The  latter  is  particularly  im- 
portant when  it  is  not  merely  a  question  of  understanding,  but 
of  acting,  or  finding  new  solutions.  The  usual  thing  is  the  idea  of 
obtaining  money  from  parents;  if  this  is  impossible  thousands  of 
young  girls  will  resign  themselves  to  what  is  apparently  unavoid- 
able.   Our  heroine  detached  the  thought  of  procuring  money  from  the 


26  TEXTBOOK  OF  PSYCHIATRY 

idea  of  the  usual  source  and  sought  a  different  one.  The  classical  wit- 
ticism of  the  egg  of  Columbus  is  a  very  striking  example  for  the 
significance  of  this  detachment.  Columbus  could  count  on  the  fact 
that  his  narrow-minded  rivals  would  not  be  able  to  detach  them- 
selves from  the  stereotyped  ideas  of  the  undamaged  egg.  If  it  were 
not  for  the  strong  resistance  of  ordinary  minds  against  the  unaccus- 
tomed, as  represented  by  the  broken  end,  the  solution  would  instinc- 
tively have  had  to  force  itself  upon  them.  One  need  merely  call  to 
mind  an  egg  of  wax. 

A  fundamentally  different  grading  of  intelligence  is  that  according 
to  clearness  of  ideas.  This  does  not  depend  on  the  number  of  pos- 
sible associations;  on  the  contrary,  in  those  who  lack  clearness  one 
often  gets  the  impression  that  there  are  too  many  associations,  or 
that  not  enough  are  inhibited.  On  the  other  hand,  there  is  not 
much  that  is  unclear  in  those  concepts  which  are  formed  by  the 
ordinary  oligophrenics  themselves.  Idiots  do  not  go  very  far  beyond 
the  material  existence  in  forming  concepts  and  that  alone  relatively 
protects  them  against  a  want  of  clearness.  Lack  of  clearness  will 
appear  at  most  if  concepts  are  forced  upon  them  from  the  out- 
side, for  the  understanding  of  which  they  are  too  feeble.  On  the 
other  hand,  there  are  intelligent  and  even  highly  gifted  people 
who  utilize  many  confused  concepts.  Under  some  circumstances  this 
may  have  a  certain  advantage  for  discoverers:  they  can  deduce  a 
hypothetical  concept  from  any  experience  without  great  difiiculty  and 
if  it  does  not  properly  conform  to  subsequent  experiences,  they  can 
without  noticeable  effort,  or  even  without  knowing  it,  transform  it 
in  accordance  with  the  new  conditions,  that  is,  they  can  use  it  in  a 
somewhat  different  sense.  It  is  self-evident  that  this  quality  is  very 
dangerous  and  can  only  be  rendered  harmless  by  very  great  intel- 
ligence. What  we  mean  here  by  confused  concepts  can  be  best  ex- 
plained by  using  the  illustration  of  the  constellations.  The  astronomer 
knows  every  star  belonging  to  Orion;  to  him  that  is  a  very  sharply 
defined  concept.  The  layman,  however,  knows  only  a  few  stars  of 
it  or  only  the  celestial  region  where  it  is  located.  But  he  is  con- 
scious of  his  weakness.  He  has  an  incomplete  but  not  a  confused 
concept  of  it.  Conscious  of  his  ignorance  he  will  not  make  the  mis- 
take of  suddenly  taking  an  entirely  different  group  of  stars  for 
Orion  and  will  not  say  that  a  comet  has  just  entered  Orion,  when 
in  reality  it  does  not  touch  Orion  at  all  or  is  just  leaving  it.  But 
the  unclear  person  may  express  himself  in  this  manner,  because  there 
are  no  definite  and  constant  limits  to  his  concepts;  he  speaks  of 
Oriqn  when  it  is  simply  a  question  of  that  legend;  at  times  he  will 


PSYCHOLOGICAL  INTRODUCTION  27 

add  to  it  stars  which  at  another  time  he  does  not  include;  what  the 
unclear  person  lacks  particularly  is  the  conscious  and  vivid  dis- 
tinction of  related  concepts.  He  who  calls  all  psycho-motor  diffi- 
culties inhibitions  may  have  a  clear  concept  of  them,  even  if  it  is 
unsuitable  for  our  diagnosis.  But  a  person  who  speaks  of  inhibition 
and  blocking  and  does  not  see  the  difference  between  these  two  terms, 
that  are  now  current  in  psychiatry,  has  an  unclear  conception  of 
them. 

There  are  people  whose  more  complex  concepts  are  all  unclear  in 
this  manner.  Many  conceal  this  defect  by  a  clever  way  of  ex- 
pression, but  in  life  they  fail  like  all  the  other  feeble-minded. 

Intelligence  in  any  sense  whatsoever  is  never  a  unit.  There  is 
no  one  who  is  eminent  in  all  psychic  fields,  while  most  idiots  naturally 
fail  in  all  directions.  Practical  intelligence  does  not  necessarily  imply 
theoretical  intelligence  and  vice  versa.  The  great  difference  between 
school  intelligence  and  worldly  intelligence  depends  only  partly  on 
the  fact  that  pedagogues  with  their  one-sided  standards  are  de- 
ceiving themselves  regarding  the  abilities  of  their  pupils.-^  A  num- 
ber of  highly  gifted  people  were  poor  in  school.  Alexander  von  Hum- 
boldt, for  instance,  "was  unfit  for  study"  according  to  the  judgment 
of  his  teachers.  And  even  after  the  school  period  "worldly  wisdom" 
is  something  quite  different  from  intelligence  in  general.  The  particu- 
lar gifts  for  mathematics,  languages,  engineering,  psychology,  philo- 
sophical thinking,  etc.,  are  well  known.  This  specialization  may  go 
to  very  great  lengths.  Indeed  there  are  people  with  one-sided  genius 
for  figuring  out  on  what  day  of  the  week  a  certain  date  will  come, 
or  for  playing  chess,  etc. 

Even  in  such  cases  we  do  not  merely  deal  with  abstract  intel- 
ligence. The  good  mathematician  not  only  has  the  ability  to  think 
mathematically  but  also  the  im-puhe  to  occupy  himself  with  it.  But 
the  intellectual  effects  depend  also  in  other  ways  on  their  inter- 
play with  other  functions,  principally  the  ajfects.  We  have  seen  in 
the  case  of  the  schoolgirl  how  the  impulse  to  think  and  act  co- 
operated in  controlling  the  circumstances.  A  people  without  a  thirst 
for  knowledge,  like  most  of  the  Orientals,  even  though  it  had  the 
greatest  intelligence  and  perhaps  a  vivid  phantasy,  would  nevertheless 
be  unable  to  accomplish  anything  in  the  sense  of  our  occidental 
technique.  The  abulic  schizophrenic  and  the  over-labile  organic  de- 
ment both  appear  demented  as  a  result  of  their  affective  disturbances. 

"Unfortunately  one  still  observes  quite  frequently  that  the  result  of  educa- 
tion and  school  training,  the  mere  acquisition  by  memorj'  of  the  subject  matter 
of  education,  is  mistaken  for  intellectual  accomplishments. 


28  TEXTBOOK  OF  PSYCHIATRY 

Mere  clearness  of  thinking,  likewise,  is  considerably  improved  if  one 
has  the  patience  and  the  impulse  to  think  a  matter  through.  Logic 
falsified  by  affects  is  constantly  seen  in  the  insane.  A  failure  of 
the  intellectual  functions  may  be  due  to  a  disturbance  of  the  equilib- 
rium between  reflective  power  and  affectivity  (apathy  on  the  one 
hand,  and  proportionate  dementia  on  the  other).  Important  above 
all,  is  the  influence  of  the  feelings  relating  to  the  ego  which  only  too 
readily  cause  an  entirely  different  standard  to  be  applied  to  one's 
own  interests  than  to  other  things.  Furthermore,  a  large  part  of 
worldly  prudence  is  due  to  perseverance.  The  ability  to  concentrate 
the  attention  in  understanding  and  elaborating  things  may  have  an 
important  influence  upon  intelligence.  The  ability  to  find  new  ma- 
terial is  favored  by  a  certain  degree  of  phantasy  or  is  perhaps  identical 
with  it,  if  by  "new"  we  do  not  merely  mean  the  correct  "new" 
material.  That  a  good  memory  considerably  aids  intelligence,  that  it 
may  even  replace  intelligence  and  conceal  the  weakness  of  it,  is  self- 
evident.  For,  the  more  intelligent  a  person  is,  the  less  need  he  has 
for  primary  memory,  which  reproduces  experiences  exactly  as  they 
have  been  experienced.  For  the  intelligent  person  uses  deduced  con- 
cepts; a  "fish"  does  not  call  to  his  mind  a  collection  of  all  the 
fishes  he  has  ever  seen,  but  he  has  for  it  a  very  abbreviated  formula 
which  is  of  a  zoological-scientific  content. 

e)     Memoey 

Everything  that  has  been  psychically  experienced  leaves  behind  a 
lasting  trace,  or  engram^.  We  recognize  this  by  the  facts,  that  the 
more  often  a  process  has  been  repeated  (practice)  the  easier  it  runs 
off,  that  past  experiences  act  in  a  modifying  way  on  some  actual 
processes,  that  repeated  experiences  are  recognized  as  repetitions,  and 
above  all  that  one  remembers  psychic  processes.  What  modification 
the  engram  represents  we  do  not  know.  In  remembering  something 
there  must  be  a  recurrence  of  a  function  resembling  a  previous  ex- 
perience, like  an  idea  of  something  perceived,  or  of  a  function  almost 
like  it,  like  the  repetition  of  a  practiced  motion.  We  designate  this 
as  an  ekphoria  of  the  engrams.  That  every  experience,  including 
unconscious  ones,  really  leaves  behind  engrams,  cannot  be  directly 
demonstrated,  but  it  seems  very  probable  from  off  hand  tests,  fur- 
nished us  by  chance  memories.  In  dreams,  hypnosis,  and  in  diseases, 
and  sometimes  also  in  the  normal  states,  experiences  are  recalled 
which  would  otherwise  be  considered  as  impossible  of  recollection, 

A  young  woman  who  could  neither  read  nor  write  reproduced  in 
a  feverish  state  Latin,  Greek  and  Hebrew  verses,  of  which  she  knew 


PSYCHOLOGICAL  INTRODUCTION  29 

nothing  in  her  normal  state.  During  her  childhood  she  lived  with  a 
clergyman,  who  was  in  the  habit  of  reciting  such  sayings.'''^  A  person 
hypnotized  in  a  drug  store  may,  under  certain  conditions,  reproduce  a 
great  many  of  the  inscriptions  on  the  glass  jars,  even  if  he  under- 
stands nothing  about  them. 

Although  every  experience  leaves  an  engram,  those  memories  which 
we  usually  utilize  are  really  products  of  very  complicated  elaborations. 
We  do  not  form  an  image  of  a  momentary  vision  of  a  certain  region 
by  confining  it  within  the  limits  of  the  field  of  vision  at  that  par- 
ticular time,  but  we  image  a  tree,  a  meadow,  a  meadow  with  trees, 
mountains,  etc.  In  short,  in  the  available  engrams,  the  experiences 
are  analyzed  and  synthesized  according  to  the  rules  of  concept 
formation. 

The  ability  to  form  engrams,  the  engraphia,  was  designated  by 
Wernicke  as  "impressibility"  (Merkfdhigkeit) — and  this  has  been 
hazily  contrasted  with  "memory."  Memory  in  this  connection  no 
longer  means  the  whole  memory,  a  designation  for  which  is  clumsily 
lacking,  but  the  retention  of  the  ability  to  ekphorize  the  engrams. 
It  is  still  unknown  in  what  respect  the  latter  may  be  regarded  as  a 
special  quality.  The  only  thing  definite  is  that  under  certain  condi- 
tions many  engrams  cannot  be  ekphorized,  and  that,  if  a  cause  for 
it  is  found  at  all,  it  has  so  far  always  been  in  something  entirely 
different  from  the  nature  of  the  engrams;  it  was  mostly  in  affective 
obstacles.  So  far  then  the  mere  inability  to  remember  has  thus  far 
not  shown  us  why  the  engrams  are  lost.  A  more  detailed  discussion 
will  be  given  in  the  chapter  on  pathology  of  memory. 

The  engrams  seem  to  last  as  long  as  the  brain  is  not  verj'  ex- 
tensively and  markedly  injured.  It  is  not  very  rare  that  apparently 
long  lost  memories  from  childhood  reappear  in  old  age  with  great 
vividness.  All  things  being  equal,  the  older  an  engram  the  greater  is 
its  resistive  capacity  to  ekphorization.  Forgetting  therefore  is  not  as 
a  rule  due  to  a  disappearance  of  the  engrams,  but  to  an  inability  to 
revive  them  as  memories  or  to  ekphorize  them  by  association. 

The  apparent  paling  of  those  pictures  of  perception  which  are 
tangibly  vivid  is  really  only  a  substitution  of  the  same  by  elabora- 
tions which  are  more  suitable  for  the  idea  and  hence  more  capable 
of  recollection.  Another  way  of  weakening  by  age  the  capacity  to 
recall  an  engram  was  shown  by  Ranschburg.-*  Material  learned  by 
heart  consisting  of  similar  components  is  more  difficult  to  reproduce 

•^Carpenter,  Mental  Physiology,  p.  437,  Tnibner,  1896,  London. 
**  Ranschburg,  Ueber  Wechselbeziehungen  gleichzeitiger  Reize  usw.  Zeitschrift 
fiir  Psychologie  67,  1913. 


30  TEXTBOOK  OF  PSYCHIATRY 

than  that  which  is  altogether  dissimilar.  In  self-observation  we  find 
that  to  a  large  extent  memories  disappear  in  a  manner  that  one  is 
at  first  uncertain  which  of  several  similar  memory  pictures  is  the 
correct  one,  and  that  gradually  so  many  possibilities  offer  themselves 
that  one  is  no  longer  able  to  choose,  or  that  one  is  altogether  unable 
to  grasp  the  correct  engram  out  of  the  great  number  of  others.  Other 
disturbances  and  falsifications  of  memory  are  determined  by  the 
affect. 

There  are  facts,  however,  which  could,  in  the  first  place,  be  ex- 
plained by  a  change  in  the  engrams.  Thus,  rooms  which  we  saw 
in  childhood  often  seem  much  smaller  in  later  life  than  we  had 
expected.  We  have  enlarged  the  image  with  the  growth  of  the  size 
of  our  body.  Whoever  studies  the  testimony  of  witnesses  in  court 
proceedings  will  be  surprised  how,  even  in  very  simple  matters,  people 
will  make  the  most  contradictory  statements  in  good  faith;  this 
naturally  occurs  most  frequently  in  the  case  of  precipitated  or  excited 
events.  But  even  without  any  particular  reason  the  errors  are  often 
very  great.  The  experiments  regarding  the  giving  of  evidence,  par- 
ticularly those  made  by  Stern's  school,^^  have  furnished  us  much 
unexpected  information  concerning  this.  Every  one  who  observes  him- 
self, even  if  only  a  little,  is  familiar  with  the  daily  irregular  falsifica- 
tions which  reproduce  a  memory  not  only  incompletely  but  change 
it  also  in  other  ways.  Thus  the  memory  image  of  a  somewhat  un- 
familiar person,  garden,  or  of  an  event  is  frequently  quite  different 
from  the  reality  of  it,  and  in  time  also  loses  regularly  in  correctness 
and  in  clearness. 

In  all  such  cases,  however,  the  original  correct  engram  con- 
tinues to  exist  together  with  the  modified  one.  For  the  error  is  often 
subsequently  corrected,  either  through  reflection  or  through  the  fact 
that  the  correct  memory  involuntarily  appears  on  some  occasion.  In 
pathological  conditions  we  can  frequently  demonstrate  that  the  cor- 
rect and  the  falsified  idea  exist  at  the  same  time. 

Such  occurrences  prove  that  in  falsifications  of  memory  we  do  not 
deal  with  alternations  of  the  engrams,  but  with  a  complex  process 
which  is  analogous  to  the  creation  of  new  ideas.  How  much  of  this 
has  taken  place  in  the  unconscious  during  the  apparent  latency  of 
the  engrams  and  how  much  during  the  act  of  recalling  is  unknown. 

Even  in  a  sober-minded  normal  person  the  falsifications  which  cor- 
respond to  an  affect,  namely,  to  the  wishes  of  the  individual,  are  very 
marked.  It  is  very  instructive  to  reread  one's  diary  after  the  lapse 
of  a  number  of  years.  One  finds  a  great  deal  which  he  no  longer 
''Stem,  Beitrage  zur  Psychologie  der  Aussage.    Barth.    Leipzig,  1903. 


PSYCHOLOGICAL  INTRODUCTION  31 

believes  even  though  it  is  written  in  his  own  handwriting.  But  on 
closer  examination  one  finds  that  the  version  of  the  diary  fits  least 
the  person  concerned. 

Ekphorization  of  engrams  can  be  either  conscious  or  unconscious. 
Unconscious  memories  of  ideas  can  only  be  demonstrated  in  a  round- 
about way,  but  well-grounded  capacities,  particularly  of  the  motor 
type,  very  easily  take  place  unconsciously.  If  we  were  once  able  to 
swim,  we  make  the  correct  swimming  motions  as  soon  as  we  get  into 
deep  water. 

The  ekphorias  that  are  most  frequently  spoken  of  are  the  con- 
scious memories.  Without  exception  they  are  probably  generated  by 
way  of  associations.  The  laws  of  memory  are  therefore  the  laws 
of  association.  The  better  drilled  an  association,  the  more  associa- 
tive paths  lead  to  an  engram,  the  easier  it  is  to  remember.  It  is 
therefore  relatively  easy  to  remember  what  has  been  brought  into 
many  relationships,  or  what  has  been  understood.  An  unintelligible 
chaos,  as  for  instance  a  story  heard  in  a  foreign  language,  cannot  be 
reproduced.  Likewise  it  is  just  as  impossible,  in  the  ordinary  con- 
scious course  of  thought,  to  revive  all  those  innumerable  engrams 
which  we  take  up  unconsciously  as  all  the  faces  of  the  unfamiliar 
people  we  meet  on  a  walk. 

The  faculty  of  memory  is  very  easily  disturbed  through  such  a 
constellation  as  recalling  something  otherwise  familiar  in  a  new 
relationship;  we  are  often  unable  to  do  so.  The  affects,  however,  as 
we  shall  see,  are  particularly  important  as  factors  inhibiting  and 
facilitating  memory.  Pleasurable  experiences  are  particularly  eas}" 
to  remember.  In  unpleasant  experiences  there  is  a  struggle  between 
two  antagonistic  tendencies;  on  the  one  side  we  have  the  one  belong- 
ing to  the  affect  in  general,  which  makes  the  memories  more  vivid, 
and  on  the  other  side  there  is  the  tendency  which  strives  to  shut  out 
everything  unpleasant,  hence  also  a  disagreeable  memory.  L^npleas- 
ant  events  are  frequently  crowded  out  of  memory,  especially  if  they 
somehow  depreciate  the  personality.  Thus  the  lapse  of  many  decades 
creates  the  idea  of  "the  good  old  times."  Most  important  of  all,  how- 
ever, are  the  actual  affects,  which  cause  only  those  memories  to  come 
to  the  surface  which  are  suitable  for  them. 

Recognition  is  a  special  form  of  memory.  If  we  hear  or  see  some- 
thing for  the  second  or  third  time  we  regularly  recognize  it  as  a 
former  experience.  One  speaks  of  a  "quality  of  familiarity"  in  the 
repeated  sensation,  but  one  is  unable  to  describe  it.  It  is  more  im- 
portant to  know  that  recognition  is  easier  than  spontaneous  recol- 
lection.    Thus,  even  if  one  is  absolutely  unable  to  remember  the 


32  TEXTBOOK  OF  PSYCHIATRY 

oriental  name  of  Alexander,  one  will  easily  recognize  it,  if  among  other 
names  Iskander  is  mentioned.  Not  every  one  is  able  to  form  a  clear 
image  of  a  person,  but  is  able  to  recognize  him  as  soon  as  he  sees 
him. 

f)  Orientation 

Present  and  former  perceptions  combine  into  orientation  as  to  time 
and  place,  so  that  one  always  thinks  more  or  less  conspicuously  of 
being  at  a  certain  place  and  at  a  certain  period  of  time,  and  con- 
nects his  memories  with  these  dates.  It  is  self-evident  that  orientation 
depends  on  memory  (for  it  is  impossible  when  memory  is  lacking), 
on  perceptions  (for  hallucinations  can  produce  an  entirely  different 
place),  and  on  attention  (for  if  we  are  absorbed  in  thought  or  in  con- 
versation while  walking  or  riding  in  a  vehicle,  we  may  suddenly  find 
ourselves  at  a  different  place  than  we  had  expected).  But  as  pathology 
shows,  there  is  besides  this  also  an  independent  function  of  orientation, 
the  disturbances  of  which  are  not  necessarily  proportional  to  the  dis- 
turbances of  other  functions.^*'  Nevertheless  we  find  no  anomalies 
of  orientation  without  a  disturbance  of  other  functions. 

Orientation  as  to  space,  which  is  constantly  controlled  by  the 
eyes,  is  of  course  much  surer  than  orientation  as  to  time,  which 
requires  an  uninterrupted  memory  record  and  has  only  a  linear 
dimension. 

Something  entirely  different  is  the  orientation  as  to  situation,  which 
tells  us  why  we  are  at  a  certain  place,  what  relationship  we  have 
to  the  other  people,  etc.  This  is  of  course  a  function  of  reflection,  as 
far  as  it  depends  on  the  understanding  of  complex  conditions.^^ 

g)  Affectivity 

Every  psychism  can  be  divided  into  two  sides,  an  intellectual  and 
an  affective.  The  latter  often  remains  unnoticed,  but  is  never  al- 
together lacking,  as  can  be  demonstrated  through  comparisons.  For 
instance,  most  people  can  immediately  answer  the  question  whether 
they  like  better  a  trapezoid  or  a  square.  It  can  be  concluded  that 
the  mere  sight  of  such  simple  figures  is  associated  with  a  feeling  of 
pleasure  or  displeasure. 

Under  the  term  affectivity  we  comprise  the  affects,  the  emotions, 
and  the  feelings  of  pleasure  and  displeasure.     The  expression  "feel- 

^  E.g.,  following  an  alcoholic  delirium,  orientation  as  to  time  and  place  some- 
times remains  disturbed  a  few  days  longer,  while  the  other  functions  appear 
quite  normal. 

"  Regarding  Wernicke's  classification  of  orientation  into  autopsychic  somato- 
psychic and  allopsychic,  see  the  disturbances  of  orientation,  p.  110. 


PSYCHOLOGICAL  INTRODUCTION  33 

ing,"  which  is  frequently  used  for  this  wiiole  group  of  phenomena,  is 
misleading.  For  it  is  also  used  to  designate  sensations  in  the  lower 
sensory  qualities,  such  as  feelings  of  warmth,  somatic  feelings,  and 
Munk's  sphere  of  feeling,  as  well  as  indefinite  perceptions  such  as 
the  feeling  of  someone  approaching.  It  is  furthermore  used  to  des- 
ignate the  result  of  inferences  originating  in  the  unconscious,  such 
as  reaching  a  diagnosis  by  a  "diagnostic  feeling,"  and  finally  it  is 
used  to  designate  complex  processes  of  cognition,  the  elements  of 
which  are  not  clear  to  us,  such  as  the  feeling  of  familiarity.  The  terms 
"affects"  and  "emotions"  are  too  limited  in  their  application,  and  they 
really  do  not  embrace  the  simple  feelings  of  pleasure  and  displeasure. 

Affectivity  includes  somatic  as  well  as  psychic  manifestations, 
which  are  sometimes  conceived  as  symptoms  and  sometimes  as  effects 
of  the  same. 

It  influences  gestures  in  the  broadest  sense;  this  includes  the 
emphasis  in  speech,  the  attitude  of  the  body  and  muscular  tone;  it 
also  influences  the  vascular  system,  as  in  blushing,  turning  pale,  and 
in  palpitation  of  the  heart;  and  it  also  affects  all  secretions,  such 
as  tears,  saliva,  urine  and  faeces;  finally  it  influences  also  the  whole 
trophic  system  of  the  body. 

On  the  other  hand^  affectivity  is  markedly  dependent  on  physical 
influences.  We  note  this  in  anxiety  of  endocarditis,  in  depressive 
irritability  of  dyspeptics,  in  the  euphoria  of  tubercular  patients  or 
alcoholics,  and  in  the  affective  manifestations  of  inner  secretions. 

In  the  psychic  field  we  must  first  mention  the  undescribable  subjec- 
tive sensations  of  pleasure,  displeasure,  joy,  sadness,  anger,  and  similar 
feelings. 

Affectivity  also  determines  our  actions.  We  strive  to  procure  and 
retain  pleasure,  that  is,  pleasurably  accentuated  experiences,  and  we 
keep  away  from  displeasure.  If  we  take  upon  ourselves  displeasure,  it 
is  only  to  avert  a  still  greater  one  or  in  order  to  obtain  some  pleasure 
which  we  value  higher  than  the  assumed  displeasure. 

Affectivity  has  a  determining  effect  upon  action  also  by  way  of 
thought  which  is  more  influenced  by  it  than  is  ordinarily  imagined.  In 
regard  to  its  content  this  is  shown  in  two  ways : 

(1)  The  path  is  cleared  for  associations  corresponding  to  an  actual 
affect,  i.e.  these  associations  are  favored,  while  all  the  others,  particu- 
larly those  incompatible  with  the  affect,  are  hindered  (the  dominating 
force  of  the  affects).  From  this  one  may  conclude:  (a)  There  is  a 
compulsion  to  occupy  oneself  with  the  emotionally  accentuated  subject. 
(Actual  emotionally  accentuated  experiences  can  only  be  ignored  in  ex- 
ceptional cases,  and  under  certain  conditions  they  absolutely  prevent 


34  TEXTBOOK  OF  PSYCHIATRY 

any  thought  in  other  directions.)  (b)  Logic  becomes  falsified.  (In  a 
state  of  euphoria,  a  person  is  unable  to  take  into  account  all  the  poor 
chances;  they  do  not  even  "occur  to  him,"  or  they  are  deliberately  dis- 
regarded in  the  logical  operation.    One  ignores  his  own  faults.) 

(2)  The  valuation,  or  the  logical  weight  of  the  ideas  which  are  in 
accord  with  an  affect,  become  enhanced,  whereas  the  value  of  irrelevant 
and  especially  of  opposing  ideas  is  depreciated.  From  this  again  one 
may  infer  on  the  one  hand,  that  there  is  a  tendency  to  occupy  oneself 
with  those  ideas  which  seem  important,  and  on  the  other  hand,  that 
there  is  a  broader  alteration  in  the  logical  operations.  A  timid  person 
puts  too  high  a  value  on  the  dangers  involved  and  too  low  a  value  on 
the  good  chances,  if  he  considers  them  at  all.  An  investigator  whose 
ambition  depends  on  one  of  his  formulated  theories  will  continually 
find  corroborations  for  it,  and  he  is  unable  to  give  full  weight  to  the 
arguments  against  it. 

The  effects  of  an  affect  manifest  themselves  differently  and  have  a 
different  significance,  particularly  in  psychopathology,  depending  on 
whether  they  are  caused  by  a  general  mood,  such  as  euphoria,  sadness, 
anxiety,  etc.,  or  whether  they  only  emanate  from  a  single  affective  idea. 
On  the  whole,  one  can  be  in  a  different  mood  and  yet  have  a  complex 
of  ideas,  which,  whether  it  is  conscious  or  unconscious  at  the  moment, 
is  endowed  with  anxiety  or  joy  or  chagrin.  In  the  latter  case  not  all 
associations  are  influenced  in  the  sense  of  this  affect,  which  controls 
the  idea,  but  only  those  which  in  any  way  touch  the  "complexes."  ^® 
Our  thinking  may  be  quite  correct  in  all  other  respects,  but  it  is  very 
one-sided  in  regard  to  some  one  who  has  angered  us,  or  some  one  with 
whom  we  are  in  love.  As  a  rule,  all  complexes  have  a  tendency  to  estab- 
lish a  relationship  between  themselves  and  the  other  experiences  (The 
onanist  imagines  that  every  one  is  looking  at  him  because  of  his  vice) , 
and  thus  lead  to  the  formation  of  false  self  references  in  both  normal 
and  pathological  people.  If  the  thought  is  difficult  to  bear,  the  whole 
complex  can  more  or  less  be  split  off  from  consciousness  and  merge 
into  the  unconscious  but  it  does  not  always  lose  its  influence  upon  the 
psyche  as  a  result.  The  effects  of  an  affectively  accentuated  complex 
are  designated  as  katathymic  by  Hans.  W.  Maier. 

The  influence  of  affectivity  upon  thought  and  action  becomes  re- 
enforced  by  its  tendency  to  spread.  In  point  of  time  the  affects  quite 
generally  outlast  the  intellectual  process  at  their  basis,  and  what  is 
more,  they  frequently  continue  for  a  long  time.  Besides,  they  easily 
"irradiate"  to  other  psychic  experiences  which  are  associated  in  some 
way  with  the  idea  having  an  affective  tone.  Thus  we  love  the  place 
"^See  the  following  page. 


PSYCHOLOGICAL  INTRODUCTION  35 

where  we  have  experienced  something  beautiful  and  we  hate  tlie  inno- 
cent bearer  of  bad  news.  Love  often  is  "transferred"  from  Uie  origi- 
nally beloved  person  to  another  who  bears  some  analogy  to  the  former 
or  it  may  be  transferred  to  an  object,  such  as  a  letter,  etc.  Even  in 
normal  conditions  it  may  happen  that  the  transferred  affect  detaches 
itself  from  the  original  idea,  so  that  the  latter  seems  indifferent,  while 
the  secondary  idea  carries  the  affect  which  does  not  properly  belong 
to  it  {Displacement  of  the  affect). 

If  a  definite  affect  persists  and  dominates  for  some  time  the  whole 
personality  with  all  its  experiences,  we  speak  of  a  mood.  The  tendency 
of  an  affect,  which  has  once  appeared,  to  continue  and  to  become  trans- 
ferred to  other  experiences,  as  well  as  its  influence  upon  thought,  facili- 
tate the  occurrence  of  permanent  moods.  But  the  latter  maj'  also  be 
the  result  of  physical  causes,  based  on  constitutionally  determined 
moods  or  as  partial  symptoms  of  temperaments,  alcoholic  euphoria, 
mania,  melancholia  and  similar  states. 

Positive  or  pleasurably  accentuated  affects  accelerate  the  train  of 
thought,  while  negative  ones  retard  it.  As  a  result  of  acceleration, 
thought  sometimes  becomes  changed  even  in  content,  it  becomes  more 
superficial; -in  a  high  degree  of  retardation  it  never  reaches  its  object. 

The  affects  possess  great  associative  power.  An  unpleasant  affect 
has  a  tendency  to  ekphorize  former  affects  of  a  similar  nature.  Thus 
an  event,  not  very  important  in  itself,  may  produce  a  great  effect  by 
reviving  affects  from  former  situations  of  similar  quality  of  much 
greater  emotional  tone.  It  is  remarkable  that  the  former  events  often 
remain  unconscious  in  this  process.  In  other  cases  the  very  experiences 
are  recalled  to  memory  in  the  first  place,  and  then  reenforce  and  modify 
secondarily  the  original  affect.  These  peculiarities  are  of  great  signifi- 
cance in  the  pathology  of  the  neuroses. 

By  inhibiting  the  ideas  which  do  not  belong  to  them  the  affects 
also  exert  a  limiting  influence  upon  the  complexes  of  ideas  accentuated 
by  them.  In  some  connections  such  complexes  form  a  whole  category 
and  between  them  and  the  other  psyche  there  exists  not  only  an  associ- 
ation readiness  for  ideas  that  can  be  utilized  compatibly,  but  there  is 
also  a  certain  association-hostility  to  anything  not  belonging  to  them. 
They  are  therefore  only  slightly  influenced  by  new  experiences  and  are 
not  easily  accessible  to  criticism.  If  the  affective  tone  is  unpleasant, 
they  are  even  readily  repressed  into  the  unconscious. 

If  such  bundles  of  ideas,  which  are  held  together  by  an  affect,  exert 
a  permanent  influence  upon  the  psyche,  we  call  them  briefly  ''com- 
plexes." 

A  complex  may  thus  be  formed  in  regard  to  a  person  who  has  dis- 


36  TEXTBOOK  OF  PSYCHIATRY 

appointed  us,  so  that  everything  connected  with  him  is  not  only  bur- 
dened with  the  unpleasant  feelings,  but  it  also  participates  in  the 
association  readiness  or  in  the  repression  which  adheres  to  the  idea  of 
this  person.  The  memory  of  the  place  where  he  lives  produces  an 
irritable  mood  and  reaction;  distant  ideas  which  would  ordinarily  never 
be  associated  with  the  person  call  him  to  mind,  or,  the  opposite  occurs, 
the  whole  complex  is  forgotten,  repressed,  so  that  we  find  it  difficult 
to  recall  even  the  names  of  his  friends.  The  complexes  are  mostly 
either  vividly  conscious,  or  later  repressed  and  unconscious.  In  both 
cases  they  influence  our  thinking,  striving  and  mimicry.  The  most 
common  complexes  are  connected  with  the  instincts  and  many  are  recog- 
nized in  the  attitude  and  in  the  whole  behavior  of  the  individual.  Feel- 
ings of  inferiority  in  any  sphere  (insufficiency  complex)  which  con- 
tribute to  the  formation  of  many  neuroses  are  very  important  and 
especially  those  with  an  ambivalent  feeling  tone.^^  Such  complexes 
may  even  acquire  a  kind  of  independence  as  far  as  certain  voices  may 
represent  a  "greatness"  that  the  patient  would  like  to  attain  and 
others  may  personify  a  weakness,  which  hinders  him  in  the  success  of 
his  plans.^° 

An  intellectual  process,  a  perception,  an  action  in  response  to  a 
stimulus,  and  a  thought,  are  all  in  a  certain  respect  partial  functions. 
We  could  imagine  that  only  a  part  of  the  psychic  organism  participates 
in  these  processes.  In  contradistinction  to  thi^,  the  affective  processes 
signify  an  assumed  attitude  of  the  whole  person.  They  participate  in 
the  affective  changes  of  all  psychic  activity,  in  the  creation  of  uniform 
striving  for  an  aim  on  the  part  of  all  associations,  in  a  general  facili- 
tation or  restraint  of  the  psychic  processes,  in  the  changing  of  the  blood 
supply  in  the  brain,  and  in  similar  mechanisms.  Intellectual  and  affec- 
tive processes  are  related  parallel  manifestations;  they  represent  the 
local  and  the  general  side  of  the  same  psychism.  Nevertheless,  they 
can  subsequently  separate  so  that  each  process  may  proceed  indepen- 
dently or  become  associated  with  other  processes  of  the  other  series.  As 
a  result  of  irradiation  an  affect  may  become  connected  with  ideas  to 
which  it  was  not  originally  related,  and  still  remain  in  contact  with 
the  original  idea,  but  it  may  also  be  completely  separated  from  it. 
Under  certain  conditions  we  may  form  a  distinct  image  of  the  death 
of  a  beloved  person,  either  while  the  event  actually  takes  place  or  later 
from  memory,  without  experiencing  with  it  the  corresponding  affect. 
On  the  other  hand,  the  idea  of  mourning  may  be  attached  to  a  secondary 

"  See  p.  125. 

•°Cf.  The  classical  self-portrayal  of  Siaudenmaier,  Die  Magie  als  experimen- 
telle  Naturwissenschaft,  Leipzig,  Akademische  Verlagsgesellschaft,  m.  b.  H.  1912. 


PSYCHOLOGICAL  INTRODUCTION  37 

idea  indifferent  in  itself,  as  to  the  perception  of  the  place  where  we 
last  saw  the  deceased  or  to  a  song.  In  such  a  case  we  are  frequently 
unable  to  understand  the  significance  of  the  affect  (displacement).  Or 
the  affect  may  become  detached  from  the  idea  it  belongs  to  without 
associating  itself  with  any  other  idea.  There  is,  for  example,  "a  freely 
floating  anxiety"  vv^hich  originally  belonged  to  a  fearful  idea  and  was 
repressed  into  the  unconscious;  one  feels  anxiety  but  docs  not  know 
why.  There  is,  however,  an  anxiety  which  cannot  be  differentiated 
from  this  one,  which  may  be  of  physical  origin,  as  in  circulatory 
disturbances  or  in  melancholia.  In  both  cases  it  may  attach  itself  under 
certain  conditions  to  some  secondary  idea,  which  in  itself  need  not  at 
all  be  endowed  with  anxiety. 

The  affects  show  more  clearly  than  anything  else  how  the  psyche  as 
a  whole  is  always  the  decisive  factor,  and  how  the  individual  ideas, 
concepts,  and  affects  which  we  emphasize  are  only  artificial  classifica- 
tions. The  taste  of  a  certain  food  may  be  very  pleasant  to  one  hungry 
and  very  unpleasant  to  one  who  has  over-eaten.  Music,  which  in  itself 
would  be  considered  pleasant,  may  be  very  disagreeable  if  it  is  not  in 
harmony  with  the  mood  of  the  listener,  or  if  he  is  disturbed  by  it,  or 
if  he  happens  to  have  very  sensitive  nerves,  or  if  he  is  in  a  state  of 
melancholy.  If  a  lunatic  gives  us  a  box  on  the  ear  it  produces  no  affect 
in  us,  but  under  different  circumstances  it  may  fill  us  with  the  greatest 
anger  or  despair.  Careful  observation  impels  us  to  make  the  general 
statement,  that  in  reality  we  never  react  to  a  single  experience  or  idea 
with  a  definite  affect,  but  that  the  affect  is  always  merely  a  part  of  the 
whole  complex  of  functions  which  forms  the  actual  psyche. 

In  human  beings  endowed  with  memory  who  do  not  merely  live  for 
the  moment,  but  form  ideas  from  the  past  and  have  ambitions  for  the 
future,  the  tendency  to  manifest  themselves  on  the  part  of  the  ideas 
and  strivings,  carrying  a  negative  affect,  conflicts  with  the  opposite 
tendency  to  keep  away  from  the  unpleasant.  Thus  if  one  has  a  feeling 
of  revenge  or  sexual  love  for  one's  mother,  which  is  intolerable  to  a 
moral  person,  he  usually  solves  this  conflict  by  shutting  the  idea  out 
of  consciousness  in  statu  nascendi.  Notwithstanding  this,  the  idea  con- 
tinues to  exist  and  may  influence  his  actions  in  a  roundabout  way,  or  it 
may  provoke  symptoms.  The  idea  has  simply  been  repressed  into  the 
unconscious.  Repression  naturally  plays  a  great  part,  in  psycho- 
pathology. 

Every  affect  has  a  tendency  to  act  in  a  definite  direction.  Because 
some  one  has  insulted  me  an  apparatus  (chance  apparatus)  results  in 
my  psyche  which  seeks  to  avenge  me,  just  as  the  accommodation  in 
the  psychological  experiment  creates  a  kind  of  transient  reflex  ap- 


38  TEXTBOOK  OF  PSYCHIATRY 

paratus,  which,  without  any  further  exertion  on  the  part  of  my  will, 
responds  to  the  appearance  of  a  red  light  with  a  pressure  of  the  right 
forefinger  on  the  button,  or  like  any  resolution  when  formed  incites 
one  to  put  it  into  execution.  The  apparatus  is  shut  off,  e.g.,  through  the 
fact  that  it  has  accomplished  its  purpose.  I  have  revenged  myself,  or 
the  experiment  is  finished,  or  it  stops  because  it  has  lost  its  purpose, 
as  when  I  become  reconciled  with  the  person  who  offended  me.  Accord- 
ing to  the  strength  of  the  affect  it  has  a  motive  power  which  can  be 
compared  with  physical  tension  of  energy.  If  the  motive  power  is  too 
weak,  or  if  the  function  of  the  apparatus  is  restrained  by  external  cir- 
cumstances of  inner  opposing  forces,  then  the  apparatus  with  its 
"tension,"  remains  inactive.  But  if  new  impulses  are  added  to  the 
same  or  even  to  a  similar  action,  the  "tension  of  the  apparatus  then 
becomes  reenforced,  so  that,  under  certain  conditions,  it  finally  over- 
comes all  obstacles  in  an  explosive  manner  and  like  an  inhibited  reflex 
it  may  even  shoot  extensively  and  intensively  beyond  the  aim.  One 
then  conceives  the  impression  of  an  "accumulation  of  affects."  Quali- 
tative departure  from  the  original  purpose,  in  the  form  of  simple 
mimetic  expressions,  such  as  exultation,  screaming,  or  smashing  of  an 
innocent  object,  may  also  occur  and  they  suffice  to  put  the  apparatus 
out  of  action.  One  then  speaks  of  a  discharge  or  abreaction  of  the 
affective  tension,  while  the  real  process  consists  in  the  dismantling  of 
the  apparatus  in  question. 

For,  if  the  apparatus  is  not  actually  put  out  of  function,  it  remains 
throughout  life  and  may  cause  in  normal  people  some  sort  of  an  incom- 
prehensible readiness  to  react  explosively  to  certain  experiences;  in 
sick  people  it  may  provoke  a  variety  of  symptoms  without  losing  any 
energy  thereby.  This  is  particularly  true  if  the  affective  complex  has 
been  repressed.  In  that  case  it  cannot  be  shut  off  by  the  conscious 
personality  and  may  continue  unrestricted  in  the  same  condition;  in- 
deed, through  similar  new  experiences  the  complex  may  even  acquire 
more  and  more  tension.  Exaggerated  sensitiveness  to  fear  in  an  adult 
may  thus  be  traced  back  to  a  repressed  terrifying  experience  of  child- 
hood which  has  been  furnished  with  tension  from  all  similar  later  ex- 
periences, without  any  knowledge  of  it  on  the  part  of  the  patient. 
Indeed,  such  an  occurrence  may  produce  the  tendency  to  experience 
similar  things  over  and  over  again. 

Chance  apparatus  occur  also  without  any  special  affects,  wherever 
there  is  an  intention  to  do  something,  even  if  it  is  simply  a  question 
of  finishing  some  thought.  Secondary  experiences  and  thoughts  of  the 
previous  day  to  which  one  often  pays  no  attention  and  which  appear 
in  dreams  also  belong  here.  Habit  too  creates  chance  mechanism  which 


PSYCHOLOGICAL  INTRODUCTION  39 

are  particularly  difficult  to  abolish,  because  they  are  not  set  for  a 
definite  aim  happening  but  once  and  the  attainment  of  which  auto- 
matically stops  the  machine. 

Affectivity  varies  greatly  in  different  individuals  and  frequently 
even  in  the  same  person  at  different  ages.  While  every  normal  person 
must  call  a  cat  a  cat  and  observe  the  general  rules  of  logic  in  order 
to  get  along  with  his  fellow-men  and  the  external  world  in  general,  he 
may  love  the  cat  or  consider  it  a  monstrous  animal.  The  individual's 
mode  of  reaction,  which  primarily  expresses  itself  in  affectivity,  is  not 
tied  to  such  narrow  standards  as  logic.  It  is  for  this  reason  that  one 
may  argue,  for  example,  whether  or  not  the  isolated  absence  of  feeling 
tone  in  moral  concepts  is  to  be  looked  upon  as  pathological. 

The  character  of  a  person  is  almost  exclusively  determined  by 
affectivity:  Animated  and  easily  changeable  feelings  constitute  the 
sanguine  temperament,  while  persistent  and  profound  feelings  the  phleg- 
matic character;  a  person  who  does  not  accentuate  the  concepts  of  good 
and  evil  with  pleasure  or  displeasure,  or  who  puts  a  weaker  accent  on 
them  than  on  egotistical  ideas  "has  a  bad  character."  Next  to  the 
quality  of  reactions  we  must  also  consider  the  rapidity  and  force  of  the 
affects  and  hence  of  the  impulses.  Jealousy,  envy,  vanity  are  charac- 
teristics as  well  as  affects.  Affectivity  is  also  responsible  for  laziness, 
energy,  steadiness,  diligence  and  carelessness. 

From  what  has  been  said  above,  the  function  of  affectivity  in  our 
psyche  is  evident.  It  determines  the  direction  and  force  of  action,  and 
through  its  endurance  and  irradiation,  as  well  as  through  its  influence 
upon  the  logical  functions,  it  provides  uniformity  and  emphasis  for 
this  action.  It  especially  regulates  social  intercourse  with  our  fellow- 
men.  Here  it  is  important  to  note  that  we  constantly  apprehend  and 
respond  instinctively  to  the  most  delicate  fluctuations  of  affects  in  our 
fellow-men. 

We  strive  for  the  pleasurable,  which  on  the  whole  consists  of  what 
is  useful  to  the  individual  or  the  genus.  The  reverse  is  true  of  the  dis- 
pleasurable.  Exceptions  to  this  are  concerned  with  experiences  which 
are  quite  rare  and  therefore  do  not  endanger  the  existence  of  the  genus, 
or  with  occurrences  to  which  the  race  has  not  yet  adapted  itself  because 
of  lack  of  time.  Thus  we  find  the  taste  of  the  beneficial  cod  liver  oil 
disagreeable,  but  that  of  harmful  alcohol  pleasant. 

That  excessive  affects  may  be  harmful  (paralyzed  with  fear,  blind 
rage)  is  quite  obvious.  Compared  with  the  daily  and  hourly  oc- 
currences in  which,  for  example,  a  very  slight  anger  or  slight  fear  is  a 
help  in  overcoming  an  obstacle,  they  are  rare  exceptions  which  cannot 
threaten  the  existence  of  the  genus. 


40  TEXTBOOK  OF  PSYCHIATRY 

Physical  pain  assumes  a  special  position.  It  accompanies  destruc- 
tive processes  in  the  body  and  is  localized  like  a  physical  sensation. 
At  the  same  time  it  is  also  a  feeling  or  an  affect  and  has  the  same 
significance.  It  forces  us  to  direct  our  attention  to  injuries  of  the  body 
and  to  ward  them  off  energetically.  There  are  also  other  "primitive 
feelings"  (v.  Monakow) ,  which  cannot  be  clearly  separated  from  our 
conception,  as  for  instance  hunger. 

h)     Attention 

Attention  is  a  manifestation  of  affectivity.  It  consists  in  the  fact 
that  certain  sensory  perceptions  and  ideas  which  have  aroused  our 
interest  are  facilitated  and  all  others  inhibited.  If  we  are  performing 
an  important  experiment,  we  only  observe  what  is  relevant  to  it;  every- 
thing else  is  entirely  lost  to  our  senses. 

If  we  wish  to  concentrate  on  a  certain  theme  we  call  to  our  assist- 
ance all  appropriate  associations  and  exclude  the  others.  The  greater 
"clearness"  of  observation  and  thoughts  to  which  we  direct  attention 
is  merely  the  expression  of  the  fact  that  everything  relevant  is  ob- 
served and  considered  while  the  irrelevant  is  eliminated.  Hence  in 
attention  the  "interest"  inhibits  and  facilitates  the  associations  in  the 
same  way  as  is  ordinarily  done  by  the  affects.  The  more  successfully 
this  is  done,  the  greater  is  the  intensity  or  the  concentration,  and  the 
greater  the  number  of  useful  associations  put  in  operation,  the  greater 
the  extent  of  attention. 

A  distinction  is  also  made  between  tenacity  and  vigility  of  attention 
which  are  usually,  but  not  always  antagonistic  to  each  other.  Tenacity 
is  the  ability  to  keep  one's  attention  fixed  on  a  certain  subject  con- 
tinuously, and  vigility  the  capacity  to  direct  one's  attention  to  a  new 
object,  particularly  to  an  external  stimulus. 

We  must  also  differentiate  between  maximum  and  habitual  atten- 
tion. Many  patients  habitually  observe  very  little,  they  do  not  orien- 
tate themselves  when  they  go  to  an  unfamiliar  place,  etc.  But  if  they 
are  induced  to  exert  their  maximum  of  attention,  they  can  do  this 
without  any  difficulties  and  sometimes  particularly  well. 

If  attention  is  directed  by  the  will,  we  designate  it  as  active:  if  by 
external  occurrences,  we  call  it  passive.  Maximum  attention  will 
always  be  active  while  habitual  attention  may  be  either  active  or  pas- 
sive. The  latter  plays  a  special  part  in  recording  the  daily  happenings 
of  one's  environment. 

The  success  of  attention  is,  of  course,  not  merely  dependent  on  the 
affect,  but  also  on  the  general  disposition  of  the  psyche.  Some  people 
are  not  capable  of  great  concentration  although  they  seem  to  possess 


PSYCHOLOGICAL  INTRODUCTION  41 

a  sufficiently  strong  and  stable  affect.  Exhaustion,  alcoholic  effects, 
and  many  pathological  states  hinder  concentration  and  tenacity.  The 
extent  of  attention  is,  of  course,  also  dependent  on  the  general  capacity 
to  form  associations,  and  it  is  therefore  not  as  great  in  people  of  lesser 
intelligence. 

The  opposite  of  attention  is  distraction,  which  shows  two  contrasting 
forms.  On  the  one  hand,  if  a  pupil  shows  a  lack  of  tenacity  in  hyper- 
vigility  he  may  be  designated  as  distracted  if  he  is  disturbed  by  every 
noise,  whereas  hypertenacity  and  hypovigility  are  characteristics  of 
the  absent-minded  scholar.  A  third  form,  which  is  pathological  in  its 
more  pronounced  manifestations,  is  due  to  an  insufficient  capacity  to 
concentrate.  The  latter  may  have  an  affective  basis,  as  in  the  case 
of  neurasthenia,  or  it  may  be  due  to  disturbances  in  association,  as  in 
schizophrenia  and  certain  deliria,  or  it  may  depend  on  more  complicated 
conditions,  such  as  exhaustion. 

Temporary  distraction  usually  originates  in  a  definite  situation.  It 
is  self-evident  that  an  affect  will  hinder  the  attention  from  being  focused 
on  something  of  quite  a  different  nature,  as  in  the  case  of  a  schoolboy 
who  is  about  to  make  a  trip  and  has  to  do  his  lessons.  But  an  affect 
of  fear  may  just  as  easily  transcend  beyond  the  mark  and  interfere 
with  even  an  adequate  reflection.  In  a  critical  situation  attention  often 
fails  us,  the  ability  to  concentrate  is  usually  entirely  lacking  and  fre- 
quently also  the  tenacity,  one  continually  wanders  away  from  the 
individual  idea,  or,  like  the  pupil  who  is  anxiously  tr^nng  to  complete 
his  lesson,  one  is  distracted  by  every  fly.  Frequently,  however,  tenacity 
becomes  too  great,  and  the  individual  is  dominated  by  one  single 
idea. 

A  process  quite  analogous  to  attention,  w^hich  is  a  sort  of  un- 
conscious and  permanent  situation  of  the  latter,  is  the  association  readi- 
ness. If  something  occupies  us  affectively,  then  the  most  various  ex- 
periences will  remind  us  of  it.  All  kinds  of  ideas  will  find  associative 
connection  with  this  idea,  even  if  it  has  not  become  actual  in  thought. 
A  person  who  is  afraid  of  being  arrested  will  easily  be  frightened  by  any 
one  who  might  in  some  way  remind  him  of  a  detective.  The  association 
readiness,  like  attention,  can  also  be  intentional^  fixed  on  certain 
things.  Thus  I  may  be  searching  for  something  in  a  book,  but  I  am 
also  interested  in  many  other  things  in  the  book  and  therefore  read 
at  random,  but  as  soon  as  I  strike  the  passage  upon  which  I  have  fixed, 
or  even  something  that  is  only  similar,  I  associate  it  with  the  desired 
subject. 

Mere  habit  may  also  produce  a  sort  of  association  readiness,  even 
if  in  a  somewhat  different  sense.    Thus  a  person  who  is  occupied  with 


42  TEXTBOOK  OF  PSYCHIATRY 

much  proof  reading  will  easily  notice  typographical  errors  in  other 
reading. 

Even  in  normal  persons  the  association  readiness  often  produces 
deceptions  which  are  very  much  like  delusions,  thus  a  person  with  a 
bad  conscience  thinks  that  he  is  everywhere  the  subject  of  observation. 

There  is  also  a  negative  fixation  of  attention  which  plays  an  im- 
portant role  in  pathology.  Here  one  does  not  wish — usually  uncon- 
sciously— ^to  consider  certain  things,  or  one  refuses  to  take  them  into 
consideration  in  reflections.  The  association  hostility  makes  itself  felt 
in  attention. 

i)     Suggestion  ^^ 

Uniformity  of  action  is  not  only  necessary  for  the  individual  with 
his  various  strivings,  but  even  more  for  a  community  of  individuals. 
Animals,  even  those  living  in  herds,  are  apparently  unable  to  com- 
municate to  one  another  ideas  of  a  predominantly  intellectual  content. 
Most  of  their  communications  are  about  the  approach  of  prey  or  of 
danger  and,  as  observation  shows,  this  is  done  mainly  through  affective 
display,  which  evokes  the  same  affects  in  the  other  members  of  the 
herd.  It  is  only  through  the  movement  of  flight  or  attack  of  the  animal 
first  seized  with  the  affect  that  the  others  learn  the  direction  of  the 
prey  or  danger.    This  is  entirely  sufiicient  for  most  cases. 

This  affective  suggestibility  is  still  fully  present  also  in  man,  in 
spite  of  his  language  which  has  been  more  and  more  developed  for  in- 
tellectual needs.  Even  the  infant  reacts  appropriately  to  affective 
manifestations,  and  the  adult  cannot  remain  cheerful  when  he  is  among 
sad  people,  not  because  of  the  ideas  at  the  basis  of  the  sadness,  but 
because  of  the  affective  display  which  he  perceives.  Because  of  the 
close  connection  between  the  affect  and  the  ideas  to  which  it  belongs 
and  because  of  the  influence  of  the  affect  upon  logic,  it  is  self-evident 
that  the  ideas  are  very  easily  suggested  along  with  the  affect,  quite 
apart  from  the  fact  that  the  object  of  this  arrangement  is  surely  also 
to  transmit  the  ideas.  Ideas  without  an  accompanying  affect  do  not 
act  suggestively.  "The  greater  the  emotional  value  of  an  idea,  the 
more  contagious  it  is."  ^^  In  conscious  suggestion,  to  be  sure,  we  usually 
deal  with  a  "pair"  of  affects  instead  of  a  uniform  affect;  in  the  sug- 

^Forel,  Der  Hypnotismus,  6th  Ed.,  Stuttgart,  Enke,  1911.  Moll,  Der  Hyp- 
notismus,  4th  Ed.,  Berlin,  Fischer,  1907. 

^^The  affect,  however,  may  be  present  merely  in  the  person  subject  to  sug- 
gestion as  when  a  remark,  indifferent  in  itself,  touches  an  affectively  toned 
complex.  A  person  with  an  incurable  disease  hears  about  a  miraculous  cure 
spoken  of  in  an  indifferent  or  even  disparaging  tone,  and  is  immediately  enthused 
to  try  it  himself. 


PSYCHOLOGICAL  INTRODUCTION  43 

gestor  there  is  the  affect  of  domination,  while  in  the  person  subject 
to  suggestion  the  affect  of  being  dominated  or  of  submissive.  Moreover, 
in  natural  suggestions,  and  even  in  animals  there  are  also  identical 
as  well  as  similar  reciprocal  relationships  of  affects.  Among  enemies 
the  fear  of  the  one  increases  the  courage  of  the  other  and  vice  versa. 

Not  only  thoughts  are  accessible  to  suggestion  but  also  perceptions, 
such  as  suggested  hallucinations,  and  all  functions  controlled  by  the 
brain,  i.e.  by  the  affects,  such  as  the  "involuntary  muscles,"  the  heart, 
the  glands,  etc.  The  influence  of  suggestion  is  therefore  much  greater 
than  that  of  the  conscious  mill,  but  it  corresponds  with  that  of  the 
affects. 

However,  the  individual  suggestion  is  not  of  great  importance  in  the 
ordinary  life  of  man.  Infinitely  more  important  is  the  suggestion  of 
the  mass,  which  even  the  most  intelligent  person  cannot  escape.  The 
swaying  of  the  masses  in  political  and  religious  movements  is  princi- 
pally done  by  suggestion,  and  not  by  logical  persuasion;  frequently 
it  is  even  quite  contrary  to  logic.  A  whole  nation  is  quite  incapable  of 
viewing  critically,  or  resisting  suggestions  which  deal  with  the  instincts 
and  impulses  of  preservation,  greatness,  power,  and  position. 

The  psychology  of  the  masses  has  laws  which  are  quite  different 
from  those  of  individual  psychology.  A  feeling  of  community  is  set  in 
motion  only  by  impulses  possessed  by  most  individuals.  The  finer 
feelings  which  are  developed  individually  only,  cannot  come  to  expres- 
sion; thus  the  masses  possess  another  more  primitive  morality  in  the 
good  as  well  as  in  the  bad  sense.  Whereas  the  feelings  become  en- 
hanced through  agreement,  the  individual's  logic  not  only  remains 
without  any  unified  connection  of  the  mass,  but  it  is  hindered  by  it; 
at  most  the  mass  permits  it  only  a  subservient  part.  Reflection,  reason- 
ing, and  the  creation  of  great  intellectual  and  spiritual  values  of  the 
mass  or  of  a  people  originate  more  from  dereistic  thinking.  Due  to 
elementary  suggestibility  the  "leader"  in  the  crowd  attains  great  power 
in  the  discovery  and  accomplishment  of  ideas.  But  sometimes  he  is 
only  the  one  who  most  definitely,  most  consciously,  or  most  forcibly 
perceives  the  chaotic  ideas  created  by  the  people,  he  is  merely  the  focus 
of  the  mass  psyche.  The  more  the  community  increases  in  numbers, 
the  more  and  more  does  the  guiding  force  become  impelled  by  obscure 
instincts,  which  are  not  clear  to  any  individual  and  of  which  the  ma- 
jority never  becomes  conscious.  They  are  likewise  difficult  to  grasp 
objectively  and  resemble  much  more  the  evolutionary  tendencies  of  the 
vegetative  or  animal  organism,  or  sudden  migrations  of  animal  species, 
than  actions  with  a  conscious  aim.  Each  individual  of  a  certain  race 
or  period  possesses  the  same  tendencies,  which  burst  forth  -^"ith  irre- 


44  TEXTBOOK  OF  PSYCHIATRY 

sistible  power  and  stubborn  persistency  from  the  "collective  uncon- 
scious," of  which  the  generally  known  "spirit  of  the  age"  is  a  partial 
manifestation.  In  chronological  succession  crowd  psychology  expresses 
itself  in  traditions,  legends,  and  similar  mechanisms ;  only  what  is  com- 
mon to  the  various  generations  is  selected  and  retained. 

Suggestion  has  the  same  significance  for  a  community  as  the  affect 
for  the  individual.  It  makes  for  a  uniform  striving  and  provides  it  with 
power  and  endurance. 

Simple  habits,  as  well  as  examples,  can  exert  very  much  the  same 
influence  as  actual  suggestion.  One  does  what  one  is  accustomed  to  do 
without  any  other  reason;  one  likes  to  do  as  other  people  do  without 
much  thought  or  feeling  in  the  matter.  In  the  latter  case,  to  be  sure, 
suggestion,  particularly  mass  suggestion,  may  easily  be  a  contributing 
factor.  Viewed  from  another  angle,  habit  also  appears  in  the  form 
of  Pawlow's  association  of  reflexes  (conditioned  reflexes),  in  which,  for 
instance,  secretion  of  saliva  is  associated  with  the  sounding  of  a  certain 
tone,  by  letting  this  note  sound  a  few  times  at  the  time  of  nourishment. 
These  mechanisms  must  theoretically  be  clearly  differentiated  from 
suggestion,  although  in  reality  they  are  frequently  mixed. 

We  also  speak  of  autosuggestion,  but  this  is  merely  a  name  for  the 
effects  of  affectivity  upon  one's  own  logic  and  bodily  function.  It  is 
of  greater  importance  in  pathology. 

Suggestibility  is  artificially  increased  in  states  of  hypnosis  which 
are  themselves  produced  by  suggestion.  In  hypnosis  the  associations 
are  so  limited  that  one  only  perceives  and  thinks  what  the  suggestor 
wishes,  that  is,  as  far  as  the  test  person  is  able  to  understand  his  wishes. 
On  the  other  hand,  the  psyche  has  far  more  power  over  the  voluntary 
associations  than  ordinarily.  The  hypnotized  person  will  guess  what  is 
expected  of  him  far  better  than  the  normal  person.  He  can  utilize 
sensory  impressions  which  would  be  too  weak  for  him  in  the  ordinary 
state.  He  can  imagine  things  so  vividly  that  he  hallucinates  them, 
but  on  the  other  hand,  he  is  able  to  shut  off  completely  from  his  psyche 
actual  sensory  impressions  ("negative  hallucinations").  He  has 
memories  at  his  disposal  of  which  he  ordinarily  does  not  know  anything. 
He  frequently  also  controls  in  a  striking  manner  the  vegetative  func- 
tions, such  as  heart  action,  the  vasomotors,  the  intestinal  movement. 
All  these  processes  may  also  be  continued  beyond  the  time  of  hypnosis, 
if  desired  (posthypnotic  effects). 

Negative  suggestibility  is  the  counterpart  of  the  positive.  Just  as 
we  have  an  impulse  to  follow  the  suggestion  of  others,  we  have  as 
primary  an  impulse  not  to  follow  or  to  do  the  opposite.  Children  at 
a  certain  age  often  manifest  this  negative  suggestibility  in  pure  form. 


PSYCHOLOGICAL  INTRODUCTION  46 

In  general,  we  see  it  very  distinctly  in  people  who  have  a  strong  positive 
suggestibility,  one  reason  perhaps  being  that  both  kinds  of  suggesti- 
bility are  two  sides  of  the  same  characteristic,  but  also  because  one  is 
in  greater  need  of  protection  through  the  negative  suggestibility,  the 
greater  the  danger  of  becoming  a  prey  to  the  positive.  The  appearance 
of  negative  impulses  beside  the  positive  is  of  the  greatest  importance. 
It  prevents  us  from  too  easily  becoming  the  sport  of  suggestions,  it 
protects  the  child  in  particular  against  an  excess  of  influences,  it  forces 
the  adult  to  reflect,  and  it  makes  self-assertion  possible  at  every  stage 
of  life. 

k)     Dereistic  ^^  Thinking 

Whenever  we  playfully  give  free  reign  to  our  phantasy,  as  happens 
in  mythology,  in  dreams  or  in  some  pathological  states,  our  thoughts 
are  either  unwilling  or  unable  to  take  cognizance  of  reality  and  follow 
paths  laid  out  for  them  by  instincts  and  affects.  It  is  characteristic  of 
this  "dereistic  thinking,"  ''the  logic  of  feeling"  (Stransky),  that  it 
totally  ignores  any  contradictions  with  reality.  Thus  the  child  and 
sometimes  the  adult  fancy  themselves  in  their  day  dreams  as  heroes  or 
inventors  or  something  else  great;  in  one's  night  dreams  one  can  realize 
the  most  impossible  wishes  in  the  most  adventurous  manner;  and  in 
his  hallucinatory  state  the  schizophrenic  day  laborer  marries  a  princess. 
Mythology  finds  it  quite  natural  to  allow  the  Easter  rabbit  to  lay  eggs 
simply  because  it  happens  that  rabbits  and  eggs  have  one  thing  in 
common,  namely,  they  are  both  sacred  to  the  goddess  Ostara  as  symbols 
of  fruitfulness.  The  paranoid  finds  a  piece  of  thread  in  his  soup  which 
proves  his  relationship  to  Miss  Threadway.  Reality  which  does  not 
fit  in  with  such  modes  of  thinking  is  frequently  not  only  ignored,  but 
actively  split  off,  so  that,  in  these  connections  at  least,  it  is  no  longer 
possible  to  think  in  terms  of  reality.  Thus  the  day  laborer  as  the  fiance 
of  the  princess,  is  no  longer  a  day  laborer,  but  the  Lord  of  Creation 
or  some  other  great  personage. 

In  the  sober-minded  forms  of  dereistic  thinking,  particularly  in 
day  dreams,  there  is  very  little  disregard  or  transformation  of  actual 
situations,  and  only  few  absurd  associative  connections  formed.  On  the 
other  hand,  dreams,  schizophrenia,  and  to  some  extent  mythology",  ex- 
ercise far  greater  freedom  in  dealing  with  the  thought  material,  where, 
for  example,  a  God  may  give  birth  to  himself.  In  these  forms  dereism 
goes  so  far  as  to  destroy  the  most  common  concepts:  Diana  of  Ephesus 
is  not  Diana  of  Athens,  Apollo  is  split  into  several  personalities,  now 
he  blesses  and  now  he  kills,  he  is  a  fructifier  and  he  is  an  artist;  indeed, 

*  Derived  from  de  and  reor  (away  from  reality,  unrealistic). 


46  TEXTBOOK  OF  PSYCHIATRY 

he  may  even  be  a  woman  although  he  is  ordinarily  a  man.  The  interned 
schizophrenic  demands  damages  in  a  sum  of  gold  which  would  exceed 
the  mass  of  our  entire  solar  system  a  trillion  times.  A  female  paranoid 
calls  herself  free  Switzerland,  because  she  should  be  free.  Similarly  in 
other  cases,  symbols  are  treated  like  realities,  and  different  concepts 
are  condensed  into  one.  Persons  appearing  in  dreams  of  normal  people 
usually  have  features  of  several  acquaintances ;  a  normal  woman  with- 
out being  aware  of  it  speaks  of  the  "hind-legs"  of  her  small  child,  which 
was  due  to  the  fact  that  she  had  fused  it  with  a  frog. 

Dereistic  thinking  realizes  our  wishes,  but  also  our  fears.  It  makes 
the  playing  boy  a  general,  and  the  girl  with  her  doll  a  happy  mother. 
In  religion  it  satisfies  our  longing  for  eternal  life,  for  justice  and  joy 
without  sorrow.  In  the  fairy  tale  and  in  poetry  it  gives  expression  to 
all  our  complexes.  In  dreams  it  serves  to  represent  the  person's  most 
secret  wishes  and  fears.  For  the  abnormal  person  it  creates  a  reality 
which  is  far  more  real  to  him  than  what  we  call  reality.  It  makes  him 
happy  in  his  delusion  of  greatness,  and  absolves  him  from  blame  if  he 
fails  in  his  aspirations,  by  attributing  the  cause  to  persecutions  from 
without,  rather  than  to  his  own  short-comings. 

If  the  results  of  dereistic  thinking  seem  to  be  sheer  nonsense  when 
measured  by  realistic  logic,  still,  as  an  expression  or  fulfilment  of 
wishes,  as  a  provider  of  consolation,  and  as  symbols  for  other  things, 
they  possess  a  kind  of  realistic  value,  a  "psychic  reality"  in  the  above 
defined  sense.^* 

Besides  the  affective  needs,  the  intellectual  ones  may  also  be  satis- 
fied in  dereistic  thinking;  but  as  yet  we  know  very  little  about  them. 
Thus  in  mythology,  the  sun  which  travels  across  the  sky  has  feet  or 
rides  in  a  carriage.  In  a  certain  sense,  however,  all  "needs"  are  affec- 
tive. At  any  rate,  affectivity  plays  an  important  role  in  dereistic 
thinking  when  it  attempts  to  give  us  information  regarding  the  origin 
of  the  world  and  the  structure  of  the  universe. 

In  its  full  development  dereistic  thinking  seems  to  be  different  in 
principle  from  empirical  thinking.  But  in  reality  one  finds  all  the  tran- 
sitions, from  the  slight  deviation  from  acquired  associations  as  is 
necessary  in  every  conclusion  drawn  by  analogy,  to  the  wildest 
phantasy. 

For,  within  certain  limits,  independence  of  habitual  trends  of 
thought  is  a  preliminary  condition  of  intelligence,  which  strives  to 
find  new  paths.  And  the  effort  to  fancy  oneself  into  new  situations, 
day  dreams  and  similar  occupations  are  indispensable  exercises  of  the 
intelligence. 

**Cf.  p.  7. 


PSYCHOLOGICAL  INTRODUCTION  47 

To  he  sure,  the  contents  and  aims  of  such  unbridled  mental  ac- 
tivities always  represent  strivings  which  most  deeply  touch  our  inner- 
most nature.  It  is  therefore  quite  obvious  that  dereintic  aims  are  valued 
much  higher  than  real  advantages,  which  can  be  replaced.^'-'  This  not 
only  explains  the  peculiar  barbarities  of  religious  wars,  but  we  can  also 
understand  why  primitives  are  fettered  with  taboo  rules,  and  similar 
superstitions,  and  why  they  exert  the  most  painstaking  efforts  not  to 
leave  a  particle  of  their  food  which  could  give  an  enemy  the  chance 
to  practice  harmful  magic  on  them.  We  can  also  see  why  we  find  it 
difficult  to  understand  how  the  savage  is  willing  to  bear  such  burden- 
some regulations,  even  if  we  compare  them  with  Chinese  or  European 
rules  of  etiquette. 

It  will  be  interesting  to  trace  the  circumstances  which  determine 
so  marked  a  deviation  of  thinking  from  reality: 

1.  We  think  dereistically  wherever  our  knowledge  of  reality  is  in- 
sufficient for  practical  needs  or  our  impulse  for  knowledge  urges  us  to 
keep  on  thinking;  this  happens  in  problems  referring  to  the  origin  and 
purpose  of  the  world  and  of  mankind,  in  problems  dealing  with  God, 
the  origin  of  diseases,  or  evil  in  general,  and  how  it  can  be  avoided.  The 
greater  our  knowledge  of  the  actual  relationships,  the  less  room  there 
remains  for  such  forms  of  thinking.  Questions,  such  as  how  winter 
and  summer  come  about,  how  the  sun  traverses  the  sky,  how  the 
lightning  is  flashed,  and  a  thousand  other  things,  which  were  formerly 
left  to  mythology,  are  now  answered  through  realistic  thinking.  2. 
Wherever  reality  seems  unbearable  it  is  frequently  eliminated  from 
our  thinking.  Delusions,  dreamlike  wish  fulfilments  in  twilight  states, 
and  neurotic  symptoms,  which  represent  a  wish  fulfilment  in  symbolic 
form,  originate  in  this  way.  3.  If  the  different  co-existing  ideas  do  not 
converge  in  the  one  point  of  the  ego  to  form  a  logical  operation,  the 
greatest  contradiction  can  exist  side  by  side,  there  is  no  question  of 
any  critique.  Such  conditions  are  present  in  unconscious  thinking  and 
perhaps  also  in  some  delirious  states.  4.  In  the  forms  of  associations 
prevailing  in  dreams  and  in  schizophrenia  the  affinities  of  empirical 
thinking  are  weakened.  Any  other  associations  directed  by  more  acci- 
dental connections,  such  as  symbols,  sounds,  etc.,  obtain  the  upper 
hand,  but  this  is  especially  true  of  those  guided  by  affects  and  all  kinds 
of  strivings. 

1)     Belief,  Mythology,  Poetry,  Philosophy 

Belief  is  closely  related  both  to  suggestion  and  to  dereistic  thinking. 
The  word  "to  believe"  has  two  meanings:  "To  accept  something  as  true 
'^Cf.  the  next  chapter  on  "Belief." 


48  TEXTBOOK  OF  PSYCHIATRY 

without  logical  proof,"  and  "to  consider  something  as  probable."  We 
confine  ourselves  here  to  the  former  concept. 

The  greatest  creeds  in  religion,  politics,  theories  of  social  position, 
esthetics,  etc.,  are  maintained  almost  entirely  through  suggestion.  Sug- 
gestion is  above  all  responsible  for  the  uniformity  in  forms  and  details, 
and  to  some  extent  also  for  the  motive  power  of  belief.  The  origin  of 
belief  always  proceeds  in  accordance  with  the  laws  of  the  affective 
mental  stream  in  dereistic  thinking.  The  several  great  creeds  serve 
as  a  definite  gratification  of  general  affective  needs,  and  for  this 
reason  they  are  so  easily  suggestible  and  possess  such  great  power 
that  in  most  cases  one  assumes  these  ideas  without  any  logical 
realitic  value.  We  wish  to  know  that  something  happens  after  death ; 
we  wish  to  feel  that  we  can  influence  fate.  The  beatiis  possidetis 
who,  in  the  face  of  misery,  wishes  to  establish  his  position  on  moral 
grounds,  acts  in  the  same  way;  and  the  sick  person  who  wishes 
to  become  well  and  therefore  believes  in  the  quack  follows  the  same 
mechanism. 

We  also  differentiate  between  belief  and  superstition;  the  latter 
contains  a  great  deal  of  magic  which  operates  with  unknown  forces, 
while  belief  has  to  do  more  with  religion  which  deals  with  our  relations 
to  a  higher  being.  But  viewed  psychologically,  there  is  principally  no 
difference  between  them ;  the  main  difference  lies  in  the  valuation  which 
is  measured  by  different  standards.  Belief  becomes  pathological  only 
when  it  dominates  the  psyche  far  too  much  and  when  it  glaringly  con- 
flicts with  the  logical  faculties  and  eventually  also  with  the  views  of 
the  individual.  But  from  this  alone,  and  without  other  supporting 
points  I  should  not  like  to  make  a  diagnosis.  The  name  of  prejudice  is 
applied  to  false  belief  or  to  superstition,  when  it  does  not  refer  contently 
to  matters  of  religion,  or  to  one's  relationship  to  fate.  This  varies  from 
the  prejudices  of  the  people  in  the  recent  war  to  the  prejudice  of  one 
individual  for  another.  Prejudice  may  at  first  actually  be  based  on  a 
mere  hasty  judgment;  but  it  can  only  derive  its  power  from  affective 
sources  by  way  of  dereism  or  suggestion. 

Poetry  and  mythology  satisfy  the  same  need  as  belief,  with  the 
difference  that  the  former  lays  no  more  claim  to  direct  realistic  value 
than  the  day  dreams  of  normal  people.  Philosophy  differs  very  little 
from  it,  in  so  far  as  it  actually  is  pure  philosophy.  (For  there  are  some 
real  sciences  classified  under  this  name,  such  as  the  deduction  of  logical 
and  esthetic  laws,  the  theorj^  of  cognition,  etc.)  The  current  explana- 
tions of  the  optimistic  and  pessimistic  theories  as  a  characteristic  ex- 
pression of  the  philosophers  originating  them,  perhaps  most  clearly 
demonstrate  the  subjectivity  of  philosophy. 


PSYCHOLOGICAL  INTRODUCTION  49 

m)     The  Personality,  The  Ego 

Most  of  our  psychic  functions  have  a  continuity,  in  so  far  as  the 
experiences  become  connected  with  one  another  through  menriory,  and 
in  so  far  as  they  unite  with  a  very  firm  and  constantly  present  complex 
of  memory  pictures  and  ideas,  namely,  the  ego,  or  the  personality.  To 
be  exact,  the  ego  consists  of  the  engrams  of  all  our  experiences  plus  the 
actual  psychism.  By  this,  of  course,  we  must  not  merely  understand 
passive  experiences,  but  also  all  our  former  and  present  volitions  and 
strivings;  the  ego  thus  really  comprises  our  entire  past  in  a  very  ab- 
breviated form.  Still,  not  all  of  these  constituents  have  the  same  value. 
At  a  given  moment  most  of  them  recede  until  they  lose  all  effectiveness, 
that  is,  they  are  not  ekphorized ;  others  are  usually,  or  always  present. 
The  composition  of  the  ego  of  individual  memory  images,  may  be  com- 
pared to  the  "public"  in  a  certain  restaurant;  individual  frequenters 
may  come  and  go,  some  are  constant  visitors,  others  come  frequenth', 
and  still  others  have  visited  the  place  only  a  few  times.  It  is  true  that 
I  have  learned  to  extract  square  roots  but  in  my  present  activity  this 
knowledge  is  almost  altogether  latent.  Certain  ideas,  however,  such 
as  who  we  are,  what  we  have  been,  and  what  we  are  now,  what  we  strive 
for  in  life,  must  be  constantly  more  or  less  clearly  present.  They  are 
part  of  the  directive  power  of  our  daily  actions.  The  fact  that  a  student 
goes  to  the  class  at  the  right  time  is  not  merely  determined  by  the  idea 
of  the  hour  and  his  schedule,  but  among  other  things  also  by  that  of 
wishing  to  study,  and  by  the  point  at  which  he  has  arrived  in  his  study. 

Thus  personality  is  not  something  changeable.  The  component 
parts  of  its  ideas  change  constantly  in  accordance  with  momentary 
aims,  but  also  in  accordance  with  experiences.  There  is  still  a  greater 
distinction  between  the  strivings  of  the  man  and  those  of  the  child;  and 
the  destinies  of  life  such  as  depression  determined  b3'  inner  causes  and 
even  toxic  influences  (alcohol)  may,  within  a  very  short  time  com- 
pletely transform  the  affective  part  of  the  personality,  which  in  some 
respects  is  the  more  important.  In  a  similar  manner  as  in  severe 
psychoses,  the  personality  may  go  to  pieces  in  the  dream.  Some  parts 
of  it  fall  away  and  are  replaced  by  others  that  are  quite  foreign  to  it. 
Thus  a  dreamer  who  in  ordinary  life  is  unassuming  may  feel  himself 
as  being  King  David,  a  gentle  person  may  commit  a  murder,  and  a 
hard-hearted  man  may  wallow  in  benevolence. 

We  also  often  attribute  to  the  person  a  special  personal  conscious- 
ness or  a  "  self -consciousness."  ^'^    These  two  expressions  contain  two 

^^  In  popular  psychology  the  expression  ''self-consciousness"  has  a  different  but 
important  meaning,  namely,  estimation  of  oneself. 


I" 


50  TEXTBOOK  OF  PSYCHIATRY 

sets  of  ideas,  the  former  represents  the  continuity  of  the  person, — ^the 
ego  of  a  normal  person  has  the  feeling  of  being  the  same  through  life — 
the  latter  deals  with  the  fact  of  rendering  the  person  prominent  and 
distinguishing  him  from  the  environment,  and  particularly  from  other 
people.  It  was  assumed  that  the  child  had  no  self-consciousness,  and 
to  prove  this  it  was  argued  that  the  child  does  not  correctly  distinguish 
its  own  person,  in  so  far  as  it  speaks  of  itself  in  the  third  person.  This 
is  wrong.  In  principle  the  child  differentiates  itself  from  everything  else 
and  also  from  other  people  just  like  the  adult.  That  it  speaks  of  itself 
in  the  third  person  has  its  obvious  reasons  which  may  be  sought  in 
the  manner  of  teaching  language  to  the  child. 

n)     The  Centrifugal  Functions 

To  assert  oneself  or  the  genus  in  accordance  with  the  aim  of  the 
psychic  apparatus,  to  make  use  of  the  environment  or  to  defend  one- 
self against  it,  is  expressed  in  every  psychism  in  a  tendency  to  react, 
or  in  a  striving.  In  a  more  complicated  being  this  finds  expression 
in  the  form  of  affectivity.  If  we  perceive  something  beautiful,  we 
would  like  to  enjoy  it,  and  if  it  is  unpleasant  we  would  like  to  ward  it 
off.  Besides  this  we  have  a  number  of  strivings  which  become  effective 
even  without  any  external  cause.  Among  these  we  may  mention  the 
impulse  to  live,  the  activity  impulse,  the  self-assertion  impulse,  the  im- 
pulse for  knowledge,  hunger,  and  the  sex  impulse.  The  activities  in 
the  sense  of  these  strivings  are  also  connected  with  pleasure.  The  in- 
stincts of  animals  evidently  represent  the  same  thing.  Principally 
there  is  really  no  line  of  demarkation  between  these  two  kinds  of 
strivings. 

In  the  countless  strivings  and  exciting  experiences  many  conflicts 
and  inhibition  must  frequently  arise.  One  would  like  to  rest  and  at 
the  same  time  drink  some  water  which  must  be  brought  from  the  well ; 
one  would  like  to  be  virtuous  and  at  the  same  time  get  rid  of  his  sexual 
tension.  Even  for  physical  reasons  one  cannot  do  many  things  at  the 
same  time.  The  inhibiting  effect  exerted  by  contrary  impulses  upon 
one  another  represents  only  another  special  case  of  the  general  law, 
namely,  that  central  functions  not  having  a  similar  aim  inhibit  each 
other.  But  if  the  force  of  one  impulse  is  not  very  much  stronger  than 
that  of  the  other,  there  results  a  competition,  whereby  in  the  "reflection" 
or  in  the  "choice  between  good  and  evil"  each  impulse  attracts  as- 
sociatively  the  material  resembling  it,  intellectually  and  affectively. 
And  under  certain  conditions  it  may  also  attract  that  which  is  contrary 
to  it,  in  the  sense  of  negative  suggestion.  Thus  arise  different  func- 
tional complexes  which  act  as  a  whole,  and  of  which  one  finally  asserts 


PSYCHOLOGICAL  INTRODUCTION  51 

itself  and  dominates  in  such  a  manner  that  the  other  is  "suppressed." 
We  designate  this  as  the  decision  or  the  act  of  volition. 

In  a  serious  struggle  of  impulses,  as  for  instance  in  a  decision  be- 
tween good  and  evil,  the  material  brought  into  play  includes  our  virtues 
and  vices,  our  entire  ethical  training,  former  decisions  to  be  good  or  to 
disregard  moral  standards,  as  well  as  our  experiences  in  former  vio- 
lations of  ethics;  in  brief,  it  involves  the  whole  personality;  "the 
decision  belongs  to  it." 

Thus  we  see  that  the  "will"  is  entirely  dependent  on  the  affects,  and 
not  merely  as  regards  its  direction,  but  also  quantitatively.  He  has  a 
strong  will,  who  possesses  energetic  feelings  which  are  not  swayed  by 
every  new  impetus.  By  a  weak  will  we  understand  quite  different  dis- 
positions: (1)  it  may  represent  a  weak  affectivity  without  motive 
power  (Abulia), ^^  (2)  it  may  evince  an  affectivity  that  is  lively  but  too 
labile,  too  easily  changeable,  one  who  follows  the  crowd  and  paves  the 
road  to  hell  with  good  intentions,  or  (3)  for  various  reasons  one  is 
unable  to  form  any  decisions. 

The  much  mooted  question  whether  there  is  a  "jree  will"  in  the 
sense  that  a  decision  can  be  reached  without  any  reason,  does  not  exist 
in  natural  science.  We  see  that  the  actions  of  living  beings  are  de- 
termined by  the  inner  organization  and  the  external  influences  reacting 
upon  them  in  exactly  the  same  manner  as  any  other  happening.  There 
is  no  decision  which  does  not  have  a  complete  causal  basis  in  motives 
and  strivings.  But  motives  and  strivings  are  either  a  complex  of 
nervous  functions,  which  is  subject  to  the  ordinary  psj'chic  laws  of  cause 
and  effect,  or  something  analogous  to  these  nervous  processes,  which  de- 
pend on  physical  as  well  as  psychic  causes.  "Motives"  are  causes  even 
though  they  are  complicated.  Science  is  therefore  deterministic  even 
in  those  cases  where  it  is  not  fully  admitted.  To  be  sure,  we  assumed 
that  one  acts  badly  "because  he  is  a  bad  fellow^"  but  we  also  know 
that  he  himself  has  not  selected  his  own  organization  but  that  he  has 
inherited  it  when  he  came  into  the  world,  or  that  it  has  been  changed 
by  some  influences  or  other  exerted  on  the  brain. 

Nevertheless,  the  subjective  feeling  of  being  free  in  one's  decisions 
is  not  an  illusion  in  the  real  sense.  Our  actions  are  the  outcome  of  our 
own  strivings,  but  as  some  of  these  contradict  each  other,  the  reaction 
follows  exactly  our  feelings  in  the  direction  of  our  strongest  impulse. 
The  act  of  volition  is  therefore  in  harmony  with  the  momentary-  aims 
of  the  psyche  as  a  whole,  that  is,  with  the  personality,  with  the  com- 
plex, which  comprises  all  strivings  and  in  which  the  latter  can  form 
a  resultant.    TT^e  do  what  we  ivish  because  we  wish  what  v:e  do,  or  to 

"Abulia  as  a  consequence  of  inabilitj^  to  reach  decisions,  see  p.  143. 


52  TEXTBOOK  OF  PSYCHIATRY 

express  it  objectively:  Volition  and  action  is  one  process,  the  two  sides 
of  which  are  individually  rendered  prominent.  This  has  an  analogy 
in  the  physical  sphere,  namely,  when  all  the  conditions  of  a  process 
or  a  state  are  present,  then  the  result  or  the  state  is  also  present.  It  is 
a  mistake  to  think  that  one  could  wish,  that  is,  act,  something  else. 
However,  one  can  covet  only  something  else.  We  make  this  mistake 
wherever  we  form  an  insufficient  estimate  of  the  causes,  even  in  the 
physical  realms;  the  concept  of  accident  is  based  on  this.  If  a  brick 
falls  from  the  roof  and  strikes  the  ground  near  a  person,  he  says,  "I 
could  have  been  struck  by  it." 

The  dispute  concerning  the  conception  of  the  will  is  a  striking 
example  of  the  power  of  emotions.  Scientifically  viewed,  determinism 
is  the  only  possible  conception.  And  yet  many  people  cling  to  indeter- 
minism  although  they  cannot  even  follow  the  thought  to  any  clear 
conclusion,  the  moralist,  because  he  has  falsely  based  his  ethics  thereon, 
the  theologian  because  in  spite  of  the  contradiction  with  God's  omnip- 
otence he  needs  it  for  his  actual  ideas,  the  jurist  because  he  thinks  that 
otherwise  his  laws,  particularly  the  penal  code,  will  be  shaken.  As  a 
matter  of  fact  it  makes  no  difference  in  practice  which  point  of  view 
one  holds.  The  penal  code,  for  instance,  would  not  have  to  change  a 
single  one  of  its  provisions,  but  only  a  few  expressions,  if  it  accepted 
the  theory  of  determinism. 

Among  the  various  impulses  of  man  the  nutritive  impulse,  which  is 
a  part  of  the  self-preservation  impulse,  is  greatly  denatured  in  our 
present  condition  and  therefore  difficult  to  study.  But  the  sexual  im- 
pulse is  still  clear  to  us.  It  shows  us  how  tendencies  of  pleasure  and 
displeasure  impel  us  to  actions  whose  natural  aim  (in  this  case  the 
preservation  of  the  species)  may  be  unwelcome  to  us,  or  not  become 
conscious  at  all.  This  is  the  case,  for  instance,  in  the  choice  of  clothing 
and  most  of  the  other  preparatory  actions  in  the  approach  of  the  sexes. 
It  also  teaches  us  to  understand  the  instincts,  which  are  defined  as  a 
capacity  to  act  in  such  a  manner  that  certain  aims  will  be  fulfilled 
without  becoming  known  or  without  being  considered,  and  without 
the  necessity  of  any  particular  training,  acquisition,  and  practice. 

The  ethical  impulses  are  of  particular  importance  for  every  being 
living  in  society.  They  preserve  the  community,  and  hence  they  often 
conflict  with  the  interests  of  the  individuals;  they  also  have  a  great 
many  points  of  contact  with  sexuality.  But  it  is  just  as  wrong  to  create 
the  impression  that  ethics  deals  with  sex  only,  as  it  is  incorrect  to 
follow  an  ethics  of  "to  &ov7  one's  wild  oats"  and  to  ignore  altogether 
the  sexual  restraints  which  are  originally  determined  by  nature.  Never- 
theless it  is  certain  that  the  existing  sexual  ethics  is  not  adapted  to  the 


PSYCHOLOGICAL  INTRODUCTION  53 

demands  of  modern  civilization.  Indeed,  our  form  of  sofiety  on  the 
one  hand  and  the  sexual  impulse  on  the  other  often  conflict  in  fiuch  a 
way  that  even  a  theoretical  solution  seems  impossible.  As  a  result 
conflicts  are  created  which  not  only  are  of  great  importance  social. y, 
but  also  medically. 

Other  definitions  of  the  word  "impulse"  will  be  discussed  at  the  end 
of  the  section  on  Psychopathology. 

An  effect  similar  to  that  of  the  congenital  impulses  is  exerted  by 
chance  apparatus  and  habits.'-^^ 

The  other  centrifugal  functions,  such  as  "psychomotility"  and 
"motility"  we  shall  pass  over  as  being  self-evident. 

''See  p.  50. 


CHAPTER  n 

GENERAL  PSYCHOPATHOLOGY 

The  symptoms  of  psychic  diseases  show  such  an  infinite  variety  of 
manifestations  that  one  is  forced  to  put  them  into  a  certain  scheme 
and  to  select  what  is  most  important  in  them.  For  it  must  be  borne 
in  mind  that  although  superficially  two  phenomena  may  look  alike, 
they  may  nevertheless  have  entirely  different  meanings,  depending  on 
their  psychic  environments  and  on  their  genesis.  Moreover,  and  this 
is  even  more  true  here  than  in  physical  pathology,  every  symptom  is 
really  only  a  special  part  of  a  general  process.  What  we,  for  example, 
described  in  the  spheres  of  association,  is  not  simply  a  disease  of  the 
associations,  but  a  general  psychic  disturbance,  from  which  we  pick 
out  one  part,  namely,  that  which  concerns  the  associations. 

For  a  scientific  study  of  the  psychoses  it  is  necessary  to  distinguish 
between  primary  and  secondary  symptoms.  Thus  a  paralysis  of  the 
abducens  nerve  is  a  primary  symptom,  whereas  the  subsequent  con- 
tracture of  the  internal  rectus  and  the  diplopia  are  secondary  symp- 
toms. A  certain  disturbance  of  mental  function  in  dementia  praecox 
is  a  primary  symptom  while  the  resulting  twilight  state  following  it 
under  the  influence  of  an  unpleasant  experience  is  a  secondary  symp- 
tom. If  a  paronoic  conceives  an  indifferent  experience  in  the  sense  of 
a  delusion  of  reference,  it  is  in  a  certain  relation  a  primary  symptom, 
but  the  reaction  following  it,  in  the  form  of  an  insult  which  is  normal  in 
itself,  is  a  secondary  symptom.  The  last  example  also  shows  that  these 
concepts  are  only  relative,  inasmuch  as  a  fundamental  disturbance 
often  produces  a  whole  casual  chain;  for  the  delusion  of  reference  is 
already  a  derivative  symptom,  in  the  particular  case. 

In  some  diseases  it  is  of  value  to  differentiate  between  principal  and 
accessory  symptom,s.  The  former  appear  in  every  one  of  these  cases 
as  soon  as  the  disease  reaches  a  certain  height.  One  must  therefore 
assume  that  in  mice  they  are  also  present  even  where  we  do  not  yet 
see  them,  that  because  of  insufficient  intensity  they  have  not  yet  crossed 
the  diagnostic  threshold.  Among  these  we  have  the  organic  symptom- 
complexes,  in  organic  diseases,  the  association  and  affective  disturbances 
in  schizophrenics,  and  the  manic  and  melancholic  states  in  manic  de- 
pressive psychoses.    The  accessory  symptoms,  like  hallucinations  and 

54 


GENERAL  PSYCHOPATHOLOGY  55 

delusions,  may  be  absent  in  these  diseases,  or  they  may  appear  and 
disappear  at  any  time  and  in  any  combinations. 


1.  DISTURBANCES  OF  THE  CENTRIPETAL  FUNCTIONS 

The  centripetal  functions  may  be  disturbed  through  disease  of  the 
peripheral  conducting  or  the  central  receptive  organs.  Under  the  latter 
one  includes  the  central  sensory  fields  as  well  as  the  whole  cortex  as 
the  carrier  of  the  psyche.  The  disturbances  in  the  conducting  organs 
can  naturally  only  be  disturbances  of  sensation,  while  those  of  the 
cortex  (respectively  the  psyche)  are  almost  only  disturbances  of 
perception  and  the  first  elaboration  connected  with  it,  namely, 
apperception. 

Disturbances  of  the  Sensory  Organs 

Disturbances  of  the  sensory  organs  appear  in  part  as  accidental 
complications  and  in  part  as  symptoms  of  individual  psychoses,  like 
paresis.  On  the  whole  they  are  of  no  importance  in  -psychopatholog>% 
still,  peripheral  irritations  may  occasionally  become  important  by  pro- 
ducing hallucinations  through  as  yet  unfamiliar  paths.  The  patient 
is  often  unable  to  recognize  the  origin  of  his  paresthesias,  and  thinks 
that  noises  in  his  ear  are  bells,  or  what  is  most  common,  the  false  sen- 
sations are  interpreted  in  the  sense  of  illusions.  Thus  buzzing  in  the 
ears  is  conceived  as  rushing  water  or  as  words,  shadows  and  light  on 
the  retina  as  visions  of  animals,  and  nervous  pains  as  physical  injuries. 

Weakness  of  the  sensory  organs  influences  the  psyche  during  its 
development  and  also  later.  Marked  short-sightedness  may  lead  to  a 
deficiency  of  perspective  or  to  a  lack  of  consideration  of  a  definite 
kind.  Thus  the  miniature  paintings  of  the  poetess  Annette  von  Drosta 
are  supposed  to  be  due  to  her  myopia.  Absolute  bliridness,  naturally, 
exerts  a  very  marked  influence  on  the  subjective  view  of  the  world, 
which  in  the  normal  person  is  in  the  first  place  optic;  it  does  not.  how- 
ever, change  the  psyche  in  its  relations  to  people. 

It  is  quite  different  in  the  case  of  deafness  or  disturbances  of  hear- 
ing. With  the  exception  of  the  modern  way  of  teaching  the  deaf  and 
dumb,  we  perceive  the  whole  cultural  achievement  of  older  generations 
directly  or  indirectly  through  hearing  and  all  our  relations  to  human 
environment  are  regulated  through  language.  (Writing  presupposes 
language.)  Hence  the  deaf  person,  without  special  instruction,  remains 
a  psychic  cripple  in  the  most  important  relations,  even  if  he  is  intelli- 
gent; and  as  he  is  unable  to  put  the  correct  value  on  the  behavior  of 
his  environment,  he  becomes  irritable,  hot-tempered,  and  suspicious. 


56  TEXTBOOK  OF  PSYCHIATRY 

Even  acquired  difficulties  of  hearing  change  the  psyche  in  both  of  these 
directions,  wherein  suspicion  is  most  prominent  and  may  even  rise  to 
the  degree  of  delusions. 

Central  Disturbances  of  the  Sensations  and  Perceptions.  Sen- 
sations are  seldom  disturbed  through  psychotic  processes.  In 
melancholic  and  neurotic  states  we  often  encounter  a  more  or  less 
general  hyperesthesia.  The  patients  not  only  suffer  much  from  the 
usual  sensory  stimuli,  but  they  also  falsely  interpret  the  stimuli.  Thus 
a  dim  light  may  seem  glaring,  knocking  on  the  door  may  be  conceived 
as  shooting,  and  the  sound  of  a  fountain  may  be  taken  as  the  hissing 
of  the  escaping  steam  from  a  locomotive.  Hysterical  and  hypnotized 
persons  may,  under  certain  conditions,  react  to  the  slightest  sensory 
impressions  in  a  manner  unperceived  by  normals. 

Hyperalgesia  too,  is  present  in  the  same  conditions  and  also  as  a 
result  of  organic  processes  in  the  nervous  system. 

Hypalgesia  and  Analgesia  are  quite  common;  they  are  centrally  de- 
termined and  present  a  great  many  different  types. 

1.  In  coma  of  epilepsy  and  other  diseases,  it  is  assumed  that  there 
is  an  absence  of  consciousness  and  hence  pain  can  be  as  little  perceived 
as  anything  else.  In  soporose  and  torpid  states  the  threshold  of  feeling 
is  generally  raised  and  the  perceived  stimulus,  too,  is  of  lesser  value 
than  in  normal  states. 

2.  In  strong  affects  attention  may  be  so  one-sided  that  one  may  not 
feel  even  the  most  severe  pain;  thus  the  officer  may  first  become  cog- 
nizant of  his  shattered  arm  when  he  attempts  to  brandish  his  sword. 
Maniacal  patients  often  injure  themselves  when  in  an  excited  state 
without  noticing  it;  but  when  their  attention  is  directed  to  the  pain 
as  in  a  minor  operation,  they  evince  great  suffering.  The  complete 
analgesia  which  one  often  observes  in  alcoholic  deliria,  perhaps  also 
belongs  here. 

3.  Hysterical  mechanisms  can  shut  off  altogether  the  feeling  of 
pain  or  confine  it  to  a  circumscribed  part  of  the  body.^  But  in 
contradistinction  to  those  evincing  organic  analgesia  the  hysterical 
patients  do  not  injure  themselves,  for  the  feelings  are  only  shut  off 
from  the  conscious  ego  but  continued  to  function  in  the  unconscious 
orientation. 

4.  Peculiar  is  the  analgesia  in  some  catatonic  patients  which  extends 
over  the  whole  body  and  can  be  so  absolute,  that  intentionally  or  acci- 
dentally, the  patient  may  sustain  the  most  severe  injuries.  It  may 
come  and  go  very  rapidly  and  is  thereby  independent  of  conscious  at- 

*This  is  not  to  be  confused  with  the  pleasure  in  fain  m  some  hysterics  and 
masochists. 


GENERAL  PSYCHOPATHOLOOY  57 

tcntion.  But  even  here,  one  perhaps  deals  with  a  blocking  of  feeling, 
of  psychogenetic  nature. 

5.  Hypalgesias  and  analgesias  in  general  paresis  are  mostly  confined 
to  the  skin,  while  the  deeper  structures  remain  sensitive.  A  paretic 
can  bite  out  pieces  of  skin  from  his  hand  in  order  to  tease  the  attendant, 
but  he  is  extremely  sensitive  when  an  effort  is  made  to  move  his  anky- 
losed  joint.  The  diminution  or  absence  of  sensations  are  to  some  extent 
mostly  dependent  (but  not  principally  so)  on  attention.  We  have  no 
comprehension  for  this  form  of  analgesia. 

Other  hypesfhesias  and  anesthesias  are  not  common  in  the 
psychoses.  Hysterical  blindness,  deafness,  and  similar  afflictions  are 
based  on  (auto-)  suggestion.  Depressed  patients  sometimes  complain 
that  their  food  has  no  taste,  that  it  feels  like  chewing  straw  or  paper, 
that  all  colors  look  equally  grey  as  if  covered  with  ashes,  but  when 
one  examines  their  sensations  they  are  found  to  be  normal.  The  same 
phenomena  may  be  produced  in  normal  persons  through  a  strong  de- 
pressive affect.^ 

We  omit  here  the  aphasic  and  agnostic  disturbances  because  they 
surely  belong  to  the  pathology  of  the  cerebral  cortex  and  not  to  the 
symptomatology  of  the  psychoses,  even  if  they  sometimes  accompany 
an  organic  mental  disease. 

Perception  and  comprehension  show  the  following  disturbances  in 
idiots.  Idiots  cannot  comprehend  anything  complicated.  They  see 
the  elements  of  an  object  but  not  the  whole  thing.  Or  they  recognize 
pictures  with  difficulty  or  not  at  all,  while  they  can  readily  identify  the 
same  things  in  nature ;  they  often  lack  the  understanding  for  perspective 
imagery. 

Perception  may  be  imperject.  In  a  clouded  state,  catatonics  and 
especially  alcoholics,  may  perceive  a  green  head  of  cabbage  as  a  rose, 
a  cucumber  as  a  sausage,  and  an  ear  of  corn  as  a  fir-cone.  All  this  is 
due  to  the  fact  that  they  do  not  comprehend  the  color  or  the  size  in 
the  whole  picture-complex.  On  the  surface  these  disturbances  resemble 
illusions,  but  they  differ  from  them  through  the  fact  that  the  alteration 
of  the  picture  has  no  meaning  to  the  patient  and  is  the  same  as  falsifi- 
cation produced  by  carelessness.  The  mistake  that  brings  about  the 
illusions  has  a  definite  aim. 

When  apperception  in  the  optical  field  is  made  difficult  by  exposing 
pictures  for  a  very  short  time,  the  following  will  be  noted:  In  organic 
psychoses  the  perception  needs  more  time  and  even  then  the  patient 

'  Cf.  Goethe  (Kanonenfieber  bei  Valmy) :  "The  ej-es  lose  nothing  in  force 
and  clearness;  but  nevertheless  it  is  as  if  the  world  assumed  a  distinct  brown- 
reddish  tone." 


58  TEXTBOOK  OF  PSYCHIATRY 

often  makes  mistakes. — In  epilepsy  the  behavior  is  the  same.  There 
seems  to  be  some  difference  but  it  cannot  be  definitely  fixed.  At  ail 
events  the  symptoms  correspond  with  the  general  retardation  of  the 
psychic  processes  in  the  patient.  In  both  groups  the  tendenc^^  to  per- 
severation expresses  itself  in  the  fact,  that  a  later  image  is  mistaken  for 
one  seen  before  (paraphasic  disturbances  should  here  be  excluded) . — In 
alcoholics  the  answers  mostly  follow  quickly  and  with  subjective  sure- 
ness;  nevertheless  mistakes  are  frequently  made  and  sometimes  they 
show  that  the  real  picture  somehow  reached  the  psyche.  Thus  mistaken 
objects  are  named  which,  although  they  show  no  optic  similarity  to  the 
picture  exposed,  they  nevertheless  are  in  some  way  related  to  it.  For 
example,  the  picture  of  an  axe  brings  the  answer  shovel,  or  the  image 
of  a  number  may  evoke  an  entirely  different  number.  In  all  these 
diseases  the  results  may  be  improved  through  exertion  of  attention, 
so  that  one  is  often  inclined  to  ascribe  such  mistakes  to  inattention 
which  would  be  incorrect. — In  profound  melancholic  states  the  apper- 
ception must  be  given  more  time  if  one  wishes  to  avoid  an  abnormal 
number  of  mistakes. — Manic  states  show  nothing  characteristic  in  the 
habitual  perception  of  their  environment,  and  in  tests  conducted  with- 
out accurate  measurements.  In  laboratory  experimentation  the 
patients  perceive  things  incorrectly  and  make  more  mistakes  than 
normal  people:  this  probably  does  not  depend  on  perception  but  on  the 
flightiness  of  attention  and  similar  factors.  Nor  are  we  aware  of  any 
real  apperceptive  disturbances  in  schizophrenia;  the  mistakes  which 
occur  here  so  often  can  be  regularly  explained  by  the  state  of  compli- 
cated functions  of  attention,  affects,  and  thinking. 

Analogous  disturbances,  though  not  so  easy  to  demonstrate,  are  also 
found  in  the  acoustic  field.  In  organic  patients  particularly,  one  is 
often  struck  by  the  fact,  that  questions  must  be  often  repeated  before 
they  are  correctly  grasped;  this  is  especially  true  when  one  changes  to 
another  theme. 

The  most  important  psychopathic  manifestations  in  the  centripetal 
fields  are  the  sensory  deceptions.  (Phantasms.)  They  are  divided  into 
Illusions  and  Hallucinations. 

Illusions  are  real  perceptions  pathologically  changed.  The  striking 
of  the  clock  becomes  an  insulting  remark  or  is  conceived  as  a  promise; 
the  grasped  hand  is  hurled  back  because  it  feels  like  a  dead  hand;  people 
are  seen  walking  on  their  heads;  instead  of  the  white  color  of  the  face, 
it  looks  black,  and  instead  of  the  nurse  one  sees  a  waitress.  The  real 
mistaking  of  personality  where  some  one  of  the  environment  is  looked 
upon  as  a  relative  or  acquaintance  of  the  patient,  or  as  the  president, 
is  rarely  a  pure  illusion;  often  it  is  a  delusion,  as  in  schizophrenia,  and 


GENERAL  PSYCHOPATHOLOGY  59 

occasionally  it  is  a  semi-  or  total  conscious  playfulness  as  in  mania. 
Most  frequently  it  is  a  process  belonging  to  confabulations,  as  in 
organic  psychosis. 

The  illusion  is  a  caricaturing  of  a  normal  process.  In  ordinary  per- 
ception it  is  only  exceptional  that  we  perceive  all  the  qualities  of  a  thing 
in  question;  the  missing  parts  we  unconsciously  supplement  and  those 
that  are  falsely  perceived  are  corrected  in  the  sense  of  the  whole 
thing.  Thus  even  the  normal  perception  is  a  sort  of  illusion.  It  is  very 
difficult  not  to  overlook  a  printer's  errors,  and  the  telephone  certainly 
does  not  give  us  all  the  consonants  with  the  required  clearness;  we 
supplement  them  without  being  aware  of  it.  It  is  only  a  difference  in 
quality,  when  during  a  markedly  affective  situation  a  tree  stump  is 
taken  for  a  highway  man,  or  a  fog  for  an  apparition  of  an  angel,  and 
yet  the  last  examples  can  no  longer  be  differentiated  from  the  illusions 
of  insane  patients. 

Hallucinations  are  perceptions  without  corresponding  stimuli  from 
without.  Everything  perceived  can  also  be  hallucinated,  and  indeed, 
this  may  be  achieved  in  a  manner,  that  the  elements  form  free 
combinations;  thus  a  lion  may  have  wings,  and  a  figure  may  be 
composed  of  attributes  from  different  persons.  Besides,  morbid  func- 
tions apparently  produce  inner  feelings,  which  never  occur  in  any 
other  way. 

The  theoretical  distinction  between  hallucinations  and  illusions  is 
not  always  self-evident.  No  sense  organ  is  ever  quite  without  a 
stimulus  ("Light,  dust"  of  the  dark  fields;  entotic  noises,  etc.),  so  that 
one  can  almost  always  speak  of  a  false  interpretation  of  a  sensory  im- 
pression. As  a  matter  of  fact,  the  so-called  visual  hallucinations  of 
alcoholic  deliria  are  illusions  based  on  irritations  of  the  senson,"  appa- 
ratus. But  as  the  stimulus  does  not  come  from  without  it  is  counted 
among  the  hallucinations.  In  hallucinations  of  smell  and  taste  one  can 
hardly  ever  exclude  sensations  of  smell  and  taste ;  the  skin  is  constantly 
touched  by  the  clothes,  currents  of  air,  as  well  as  similar  stimuli. 

One  cannot  decide  whether  one  deals  with  hallucinations  or  illusions 
in  the  case  of  voices  coming  "from"  the  whistling  of  the  wind  or  the 
rattle  of  the  wagon,  which  are  perceived  simultaneously  with  the  noises 
causing  them. 

In  most  cases  the  differentiation  is  simple.  Visions  which  are  not 
connected  with  definite  objects  are  undoubtedly  hallucinations,  the  same 
is  true  of  words  which  are  heard  as  coming  from  the  wall,  and  this  is 
especially  confirmed  in  both  cases  when  the  optic  and  acoustic  nerves 
furnish  beside  a  great  many  other  stimuli. 

Hallucinations  may  be  graded  according  to  three  directions:  the 


60  TEXTBOOK  OF  PSYCHIATRY 

clearness  of  the  projection  to  the  outer  world,  the  clearness  of  the  per- 
ception, and  the  intensity.  These  qualities  are  independent  of  one 
another. 

The  projection  to  the  outer  world  is  usually  perfect.  What  the 
patients  see  and  hear  they  accept  as  impugnable  reality,  and  when 
hallucination  and  reality  contradict  each  other  they  mostly  conceive 
what  is  real  to  us,  as  unreal  and  falsified.  It  is  of  no  avail  to  try  to 
convince  the  patient  by  his  own  observation,  that  there  is  no  one  in 
the  next  room  talking  to  him;  his  ready  reply  is  that  the  talkers  just 
went  out  or  that  they  are  in  the  walls  or  that  they  speak  through  in- 
visible apparatus. 

However,  hallucinations  evince  all  gradations.  There  are  hallucina- 
tions which  are  recognized  as  hallucinations  but  are  none  the  less 
perceived  with  perceptible  distinctness  (Kandinsky's  Pseudo-hallucina- 
tions) ;  others  concerning  which  the  patient  cannot  say  whether  they 
are  visions  or  vivid  imaginations,  whether  they  are  voices  or  "inspired" 
thoughts  ("psychic  hallucinations"),  and  so  they  gradually  shade  off 
until  they  reach  the  usual  thoughts  and  ideas. 

The  patients  often  localize  in  the  body  the  voices,  and  sometimes 
also  the  visions  (mostly  in  the  chest,  sometimes  in  the  head,  and  oc- 
casionally even  in  any  other  part  of  the  body). 

Projection  is  facilitated  through  a  high  perfection  of  the  image.  Still 
hallucinations  often  show  the  vagueness  of  ordinary  ideas ;  although  the 
patient  often  sees,  definitely,  a  "dog,"  he  is  nevertheless  unable  to  tell 
anything  about  the  breed,  color,  size  and  the  position  of  the  dog.  While 
the  patient  himself  is  never  conscious  of  this  deficiency,  it  may  furnish 
the  physician  important  suggestions  that  we  deal  here  with  an  illusion. 
One  cannot,  however,  reason  the  other  way,  for  there  are  also  hallucina- 
tions endowed  with  the  perfection  of  an  actual  perception. 

Remarkable  are  the  "extracampine"  hallucinations  which  are 
localized  outside  of  the  sensory  field  in  question.  In  the  nature  of  the 
thing  one  deals  mostly  with  visions,  the  patient  sees  with  perfect  sensory 
distinctness  the  devil  behind  his  head,  but  it  may  also  concern  the 
sense  of  touch;  thus  the  patient  feels  how  streams  of  water  come  out 
from  a  definite  point  of  his  hand.  Whether  voices  which  seem  to  come 
from  thousands  of  miles  should  be  designated  as  extracampine  or  not, 
is  arbitrary. 

Sometimes,  and  this  is  most  frequent  in  alcoholic  deliria,  the  dis- 
tinctness of  the  projection  fluctuates  with  the  intensity  of  the  disease, 
instead  of  real  things,  the  convalescent  alcoholics  see  in  the  hallucina- 
tions only  "images"  which  are  shammed  for  their  benefit;  other  patients 
maintain  that  the  voices  are  only  produced  to  deceive  them  or  they  are 


GENERAL  PSYCHOPATHOLOGY  61 

"dreams."  Still  such  indistinct  projections  arc  also  present  at  the 
height  of  the  disease. 

Intensity  fluctuates  from  the  loudest  reports  of  a  cannon  to  the 
hardly  audible  whispering,  from  the  most  glowing  light  to  the  dimmest 
shadow.  During  actual  attacks,  especially  in  schizophrenia,  the  in- 
tensity may  rise  and  fall  with  the  intensity  of  the  attack. 

The  distinctness  is  sometimes  extremely  obtrusive;  it  may,  how- 
ever, sink  to  dissipating  cloudlike  figures,  to  confused  voices  and  in- 
distinct whispering,  for  the  understanding  of  which  the  patient  is  forced 
to  exert  all  his  attention.  At  all  events  the  patients  seldom  conceive 
the  indistinctness,  for  they  understand  what  the  hallucination  tells 
them. 

Of  other  qualities  of  sensory  deceptions  the  following  may  be  men- 
tioned: the  visual  hallucinations  of  alcoholic  dcliria  which  show  a 
tendency  to  be  moving,  multiform,  small,  and  without  color;  the  visual 
hallucinations  of  touch,  in  cocaine  insanity  are  often  microscopically 
small.  Visions  showing  a  tendency  to  become  greater  and  greater  and 
which  at  the  same  time  in  most  cases  seem  to  come  nearer  and  nearer 
are  usually  connected  with  anxiety. 

Hallucinations  may  be  changeable  or  stable.  The  voices  are  often 
abrupt  and  fragmentary.  Auditory  hallucinations  put  together  in  a 
dramatic  fashion  point  to  alcoholism,  particularly  alcoholic  insanity. 
Connected  hallucinations  which  fit  together,  accompanied  primarily 
by  visual  illusions  are  found  in  hysterical  twilight  states,  and  also  in 
other  cases.  Occasionally  one  finds  one-sided  hallucinations,  particu- 
larly in  one-sided  lesions  of  the  sensory  organs  or  of  the  sensory  fields 
and  tracks  in  the  brain. 

The  relation  to  the  real  perception  varies.  Voices  can  naturally 
be  localized  anywhere,  in  the  next  room,  in  the  walls  and  in  open 
spaces.  Visions  come  in  conflict  with  reality.  Thus,  behind  the 
hallucinated  man  one  cannot  see  anything  of  reality,  or  he  appears 
transparent  (ghosts).  A  hallucinated  person  can  be  placed  in  the 
midst  of  reality.  Thus  a  skull  may  be  seen  over  the  shoulder  of  a 
neighbor,  etc.  In  most  cases,  however,  the  manifestations  are  inde- 
pendent of  reality.  The  whole  environment  may  be  changed  halhicina- 
torily.  Thus  a  patient  imagines  himself  in  heaven  instead  of  the 
observation  ward. 

The  patients  are  often  cognizant  of  the  hallucinations,  not  exactly 
that  they  are  false  sensations,  but  they  feel  that  there  is  something 
strange  about  them.  Thus  they  know  them  through  their  different 
content,  they  state  that  they  have  feelings  that  they  have  never  ex- 
perienced before,  for  the  expression  of  which  they  have  to  coin  new 


62  TEXTBOOK  OF  PSYCHIATRY 

words.  They  feel  that  they  see  remarkable  images  and  scenes,  ab- 
normal localizations,  voices  in  the  walls  or  in  their  own  arms,  a  light 
in  their  own  body  or  in  the  uterus  of  a  passing  woman.  They  also 
recognize  the  strangeness  through  indefinite  projection  to  the  outer 
world.  The  patient  believes  that  he  hears  through  his  leg  and  not 
in  his  ears ;  he  does  not  know  whether  he  touches  an  animal  or  sees  it. 

The  relation  of  the  hallucinations  to  the  other  mental  content  is 
remarkable.  At  the  height  of  the  disease  the  hallucinations  in  most 
cases  have  not  only  the  reality  value  which  is  unimpugnable  to  the  pa- 
tient but  they  also  have  contently  a  compulsive  power.  Thus  if  a 
healthy  person  would  hear  a  command  ("Kill  your  child"),  it  would 
never  occur  to  him  to  follow  it,  but  the  patient  obeys  it  with  or  without 
resistance.  That  has  nothing  to  do  with  the  form  of  the  command, 
with  the  clouding  of  consciousness,  or  with  the  dementia,  for  the  last 
named  conditions  are  often  absent,  but  it  is  due  to  the  fact  that  the 
hallucinations  originate  from  the  strivings  belonging  to  the  personality 
of  the  patient.  It  is  for  that  reason  that  the  patients  find  it  so  difficult 
to  ignore  their  hallucinations.  Thus  a  paranoid  patient  suffering  from 
pneumonia  does  not  bother  about  the  inflammation  of  the  lungs,  but  oc- 
cupies herself  with  the  hallucinated  prolapse  of  the  rectum;  a  real  mis- 
fortune is  barely  noticed  while  the  hallucinated  one  lays  claim  to  the 
whole  personality.  On  the  other  hand,  patients  in  an  alcoholic  delirium 
often  view  their  conditions  like  an  audience  in  the  theatre,  and  de- 
mented schizophrenics  may  even  constantly  hallucinate  and  apparently 
pay  no  attention  to  it. 

Because  the  hallucinations  really  only  express  the  thoughts  of  the 
patient,  be  they  conscious  or  not,  it  is  quite  comprehensible  how  definite 
explanations  are  readily  given  to  apparently  incomprehensible  hallu- 
cinations. Thus  a  patient  hallucinates  the  word  "clean," — nothing  else, 
and  becomes  very  excited  over  it  because  one  means  to  tell  her  by  this 
word  that  she  has  soiled  the  bed.  A  great  many  definitely  recognize 
poisons  in  hallucinated  odors  and  tastes,  the  real  odor  of  which  they 
do  not  at  all  know. 

This  also  shows  the  possibility  of  teleologic  hallucinations  which 
give  the  patient  good  advice  or  warn  or  prevent  him  from  doing  some- 
thing which  would  harm  him.  Thus  the  dead  mother  holds  him  back 
at  the  last  moment  from  committing  suicide,  an  hallucinated  physical 
resistance  prevents  him  from  throwing  himself  out  of  the  window.  The 
Maid  of  Orleans  is  told  by  the  Holy  Virgin  what  to  do  in  order  to 
conquer,  but  this  only  took  place  as  long  as  the  war  situation  was  so 
simple  that  the  girl's  reason  could  grasp  it. 

A  similar  situation  prevails  when  the  so-called  "voice  of  conscience" 


GENERAL  PSYCHOPATHOLOGY  63 

criticizes  the  actions  and  thouf^hts  of  the  patient,  be  they  just  or  evil. 
Sometimes  warning  and  enticing,  friendly  and  hostile  voices,  become 
separated  into  two  persons  which  are  endeavoring  to  persuade  the 
patient. 

Whereas  in  one  case  the  hallucinations  appear  quite  strange  to  the 
conscious  personality  of  the  patient, — a  circumstance  which  he  uses  as 
a  proof  for  the  exogenous  origin  of  the  voices,  "Such  thing  I  really  have 
never  thought  of," — in  another  case  they  are  intimately  connected  with 
the  patient's  thoughts.  The  latter  case  is  most  pronounced  in  the 
so-called  "thought-hearing"  (wrongly  called  "double  thinking"),  where- 
by the  patient's  own  thoughts  seem  to  be  uttered  by  others.  This 
occurs  frequently  during  reading.  It  is  remarkable  that  the  voices 
can  also  utter  what  is  contained  in  one  or  many  lines  perceived  by  the 
eye  at  the  time. 

Some  patients  are  filled  with  their  hallucinations  and  can  talk  of 
nothing  else,  while  others  either  will  not  or  cannot  give  any  informa- 
tion about  them.  This  is  particularly  true  of  schizophrenia  where  the 
hallucinations  or  the  memories  of  them  are  easily  blocked  from  the 
other  content  of  consciousness. 

Many  patients  assume  as  facts  even  the  most  nonsensical  hallu- 
cinations. Others  seek  to  explain  them  by  machines,  or  by  distant 
physical  effects  of  all  sorts.  Nowadays  one  seldom  hears  of  demoniacal 
influences.  Some  patients,  who  feel  that  their  thoughts  are  read  by 
others  imagine  themselves  to  be  transparent.  Still  others  believe  that 
hearing  voices  signifies  the  attainment  of  a  special  faculty. 

Causation  of  hallucinations.  Hallucinations  accompany  many 
mental  diseases,  toxemias,  marked  exhaustions,  and  normal  sleep.  In 
the  psychoses  their  appearance  is  facilitated  by  an  absence  of  sensory 
stimuli,  thus  the  darkness  of  the  night  favors  visions,  and  the  quietude 
of  the  prison  auditory  hallucinations.  On  the  other  hand,  real  stimuli 
sometimes  act  as  exciting  causes,  thus  auditory  hallucinations  may 
appear  even  during  a  noise.  Many  patients  close  their  ears  in  order 
to  hear  the  voices  well,  and  others  in  order  to  rid  themselves  of  them. 
Occupation  (distraction  of  attention)  sometimes  hinders  them  and 
more  seldom  promotes  them. 

Exogenous  experiences  as  well  as  thoughts  may  give  rise  to  hallu- 
cinations and  determine  their  content  when  it  is  more  a  question  of 
heightening  of  the  momentary'-  disposition.  Thus  the  patient  seeing 
dishwater  carried  past  him,  hallucinates  the  insulting  remark  "food- 
spoiler,"  or  seeing  the  grass  cut,  he  feels  himself  cut  with  every"  stroke 
of  the  scythe.  Other  patients  feel  themselves  "spooned  in,"  if  some 
one  eats  near  them,  or  hearing  a  key  turned  in  the  lock  they  feel  it 


64  TEXTBOOK  OF  PSYCHIATRY 

painfully  in  their  hearts.  As  a  perception  in  one  sensory  field  produces 
hallucinations  in  another  field,  one  speaks  in  such  cases  of  Reflex 
hallucinations.  This  is  certainly  an  incorrect  conception  of  the 
mechanism. 

Visual  hallucinations  (visions)  usually  come  in  conflict  with  the 
surroundings  and  may  also  be  corrected  through  other  senses  (touch, 
resistance).  They  are  therefore  rare  during  the  day  and  in  clear 
patients,  but  they  easily  dominate  delirious  and  twilight  states.  At 
times  they  lack  the  third  dimension,  and  more  than  any  other  hallu- 
cinations they  show  an  indifferent  content.  Thus  the  patient  imagines 
that  he  witnesses  a  theatrical  performance  which  has  nothing  to  do 
with  him. 

It  is  quite  different  with  auditory  hallucinations.  In  language  they 
express  as  voices  all  things  that  move  man:  The  patient  is  abused, 
insulted,  threatened,  and  hears  the  wailing  of  maltreated  relatives; 
on  the  other  hand,  he  also  receives  joyous  promises,  orders,  and  other 
messages.  He  can  enter  into  conversation  with  the  voices,  but  in  most 
cases  he  need  not  talk  loudly  to  them,  they  answer  even  to  his  thoughts. 
The  voices  communicate  with  the  patient  from  any  distance,  and 
through  all  possible  hindrances  by  means  of  the  most  secret  paths  and 
through  apparatus,  especially  invented  for  this  purpose.  "The  voices" 
not  only  talk  but  electrify  him,  poison  him,  and  make  thoughts  for 
him;  they  become  embodied  in  the  persons  who  have  any  dealings  with 
him. 

Auditor}^  hallucinations  without  words  are  not  so  prominent.  In 
ecstasies,  fever  deliria  and  especially  in  delirium  tremens,  one  often 
hears  music  and  singing  but  otherwise  one  rarely  encounters  this  type 
of  hallucination. 

Hallucinations  of  smell  and  taste  rarely  appear  alone.  In  ecstasies 
and  occasionally  in  the  later  stages  of  manic  paresis,  they  enhance  the 
great  pleasure;  in  schizophrenic  delusions  of  persecution  they  reveal 
some  disgusting  and  some  poisonous  substances,  including  also  pitch 
and  sulphur.     Other  tastes  and  smells  are  only  very  rarely  hallucinated. 

Cutaneous  sense.  The  sense  of  touch  {''Haptic  Sensory  decep- 
tions") hallucinates  vividly  only  in  delirium  tremens,  where  small 
animals,  bugs,  tight  bands,  and  mucous  threads  are  felt.  They  are  also 
found  in  connection  with  bodily  hallucinations,  inasmuch  as  snakes 
which  crawl  to  the  genitals,  blows,  stabs,  and  similar  hallucinations  are 
also  felt  by  the  sense  of  touch.  The  other  qualities  of  the  cutaneous 
hallucinations  are  still  more  difficult  to  differentiate  from  the  following: 

Hallucinations  of  general  sensations  of  the  bodily  organs  are  wont 
to  appear  in  great  numbers  in  schizophrenia.     The  patients  feel,  how 


GENERAL  PSYCHOPATHOLOGY  65 

their  liver  was  turned,  the  lung  sucked  dry,  the  intestines  torn  out,  the 
brain  sawn  apart,  and  the  joints  stiffened,  or  how  they  are  beaten, 
burned,^  and  electrocuted  ("physical  delusions  of  persecution").  Here 
belong  also  the  very  common  sexual  hallucinations,  which  seldom  cause 
pure  pleasure,  but  mostly  great  pain.  The  patient  feels  that  his 
"nature"  is  drawn  from  him,  his  genitals  are  squeezed,  and  his  semen 
is  driven  inside  of  him.  Women  feel  themselves  violated  in  the  worst 
way. 

The  physical  hallucinations  can  be  differentiated  from  paresthesias 
mostly  through  the  fact  that  the  patients  feel  the  former  as  "done"  from 
without. 

Some  authors  associate  the  physical  hallucinations  with  the  self- 
preservation  impulse,  with  the  affectivity;  they  are  supposed  to  be  in 
most  intimate  relation  to  the  ego.  There  may  be  some  truth  in  this, 
but  what,  is  difficult  to  say. 

Hallucinations  of  kinesthetic  sensations  are  most  frequently  seen  in 
delirium  tremens,  where  the  patients  imagine  that  they  are  at  work 
while  they  lie  in  bed.  It  also  happens,  that  they  suddenly  feel  their 
seat  swinging  under  them,  or  see  objects  moving.  Schizophrenics  may 
have  the  feeling  that  one  of  their  joints  is  moved.  Instead  of  expressing 
themselves  in  voices,  the  thoughts  sometimes  manifest  themselves  in 
kinesthetic  hallucinations  of  the  speech  organs,  so  that  the  patients 
imagine  that  they  say  something  while  in  reality  their  speech  apparatus 
remains  quiet.  "Vestibular"  hallucinations  produce  the  feeling  of 
floating  and  falling. 

Also  pains  can  be  hallucinated,  but  it  is  not  always  easy  to  differ- 
entiate them  from  other  functional  pains. 

The  hallucinations  of  the  various  senses  frequently  combine  with 
one  another;  thus  one  sees  and  hears  a  man  and  feels  his  influence,  or 
one  sees  and  touches  objects. 

As  elementary  hallucinations  in  the  optic  field  we  designate  such 
unformed  visions  as  lightning,  sparks,  and  cloudlike  partial  darkening 
of  the  visual  field,  and  in  the  acoustic  field,  the  simple  noises  such  as 
murmurs,  knocks,  and  shooting. 

Negative  hallucinations,  or  not  to  perceive  an  object  which  is  acces- 
sible to  our  senses,  are  rare  occurrences  in  pathology  but  they  can  easily 
be  produced  in  a  state  of  hypnosis  through  suggestion. 

"Retroactive  hallucinations"  is  another  name  for  hallucinations  of 
memory. 

Many  authors  include  under  the  hallucinatory  disturbances  also  the 

'Continuous  uncontrollable  burning  in  the  form  of  paresthesia  is  mostly  a 
symptom  of  a  brain  lesion. 


66  TEXTBOOK  OF  PSYCHIATRY 

secondary  sensations  or  synaesthesias.  The  peculiarity  of  the  latter 
lies  in  the  fact  that  sensations  of  one  organ  are  accompanied  by  sensa- 
tions of  another  sensory  field.  The  most  common  form  is  "color 
hearing,"  that  is,  a  feeling  of  color  on  hearing  of  sounds  or  the  vowels 
("photism").  However,  the  secondary  sensations  have  nothing  to  do 
with  hallucinations  and  in  any  case  they  have  as  yet  no  meaning  in 
pathology. 

The  theory  of  hallucinations  is  very  instructive.  There  are  still 
psychiatrists  who  cannot  think  of  an  hallucination, — that  is,  a  pro- 
jection of  ideas  with  perceptible  distinctness  into  space, — without  the 
cooperation  of  the  peripheral  sense  organs.  For  they  maintain  that 
under  normal  conditions  only  those  processes  can  be  projected  to  the 
outer  world  which  are  accompanied  by  the  corresponding  sensory 
stimuli.  But  since,  as  far  as  we  know,  we  only  perceive  processes  in 
the  cortex,  directly  "through  consciousness,"  this  conclusion  is  not 
binding,  and,  aside  from  other  reasons,  is  false,  because  one  can  also 
hallucinate  when  the  peripheral  sensory  organs  are  destroyed. 

It  is  then  assumed  that  there  are  perception  cells  or  perception 
centres  in  the  cortex;  and  that  when  they  are  normally  put  into 
"strong"  activity  by  the  periphery  they  produce  sensations  and  per- 
ceptions in  the  organ  of  thought  (the  whole  cerebral  cortex) ,  and  when 
put  into  "weak"  activity  they  give  rise  to  ideas.  If  we  could  speak 
at  all  about  the  "strength"  of  such  processes  we  would  say  that  it  haa 
nothing  to  do  with  the  difference  between  perception  and  ideas.  And 
principally  it  has  just  as  little  to  do  with  localizations.  Even  the 
simplest  psychic  element,  as,  for  example,  the  sensory  sensation  of  blue, 
is  a  far  reaching  psychic  elaboration  of  the  mere  incoming  stimulus; 
just  let  us  imagine  the  process  of  singling  out  the  individual  color  feeling 
from  the  chaos  of  all  synchronous  sensations  and  psychic  processes  in 
general.  The  pure  sensory  element  of  perception,  as  the  most  vivid 
idea  or  hallucination,  must  perforce  be  something  just,  or  nearly,  as 
diffuse  as  the  "idea."  Nor  is  the  most  essential  part  in  the  "projection 
to  the  outer  world,"  in  the  "reality  judgment,"  which  lies  in  perception, 
or  in  the  substantiality  of  the  latter.  In  the  case  of  artists  or  in  pseudo- 
hallucinations,  "ideas"  may  be  so  clear,  so  sharp,  so  detailed  and  vivid 
in  color,  tone,  and  in  all  other  sensory  qualities  that  in  this  regard  they 
differ  in  no  way  from  perceptions,  but  they,  nevertheless,  lack  the 
reality  character  of  hallucinations  or  perceptions.  Conversely,  the 
accuracy  and  substantiality  of  the  psychic  structure  may  be  absent  in 
sensor>'  perceptions  (in  fogs,  dawTi,  etc.),  and  hallucinations  may  show 
so  much  resemblance  to  the  most  flighty  ideas,  that  the  patient  could 
not  say  definitely  in  what  words  a  hallucinated  thought  was  heard, — 


GENERAL  PSYCHOPATHOLOGY  67 

and  nevertheless  it  may  have  such  an  unshakcable  rcahty  judgment, 
as  if  I  saw  my  own  hand  in  front  of  me  in  broad  dayli^^ht.  The  reality 
judgment,  the  substantiality  of  a  true  or  hallucinated  perception, 
depends  almost  altogether  on  the  psychic  environment.  The  difference 
between  perceived  and  imagined  space  is  an  invention  of  speculative 
psychology.  If  I  looked  at  the  table  and  then  turned  my  back  on  it, 
it  still  exists  for  me  in  the  same  true  reality,  and  in  the  same  place  as 
at  the  moment  before,  when  I  looked  at  it.  The  same  holds  true  when 
I  look  at  a  coin  on  the  table  and  then  cover  it. 

At  all  events,  the  ideas  represent  reality  to  the  naive  consciousness 
just  like  the  perceptions,  although  one  soon  learns  to  make  a  certain 
distinction  between  them.  One  also  reacts  to  them  as  to  perceptions — 
they  have  the  meaning  of  timely  prolonged  perceptions.  If  I  run  away 
from  a  persecutor,  I  need  not  see  him  or  hear  him  ever>'  moment.  Thus 
we  understand  the  continuous  scale  from  the  most  abstract  idea  to  the 
one  with  sensory  distinctness  of  the  pseudo-hallucination.  The  more 
one  abstracts  from  the  sensory  components  and  from  the  details  of  a 
physical  idea,  the  lighter  is  the  "sensory  distinctness."  The  latter  does 
not,  however,  altogether  determine  the  reality  judgment  and  the  sub- 
stantiality, although  it  naturally  may  contribute  to  the  conclusion  that 
a  manifestation  is  "real."  Besides  this  there  is  another  scale,  which 
can  more  or  less  definitely  furnish  substantiality  to  an  idea  regardless  of 
whether  the  latter  has  sensory  vividness  or  not.  However,  the  distinc- 
tion is  less  delicate  here,  in  most  cases  one  is  simply  confronted  with  the 
absolute  question,  "real  or  not?"  The  appearance  of  a  saint  is  con- 
ceived by  the  normal  minded  modern  person  as  a  vision  (=  pseudo- 
hallucination),  whereas  the  devout  may  consider  it  as  a  real  mani- 
festation of  the  saint. 

We  must  distinguish  two  types  of  hallucinations.  The  first  repre- 
sents ideas  projected  to  the  outer  world;  this  is  the  hysterical  type. 
The  second  type  represents  illusionally  misinterpreted  paresthesias. 
Thus  the  irritations  of  the  optic  organs  in  delirium  tremens  produce 
visions  of  animals  while  those  of  the  cutaneous  nerves,  perceptions  of 
threads  or  needles;  in  schizophrenia  the  processes  of  the  brain  lead  at 
first  to  paresthesias  and  hypochondriacal  sensations,  and  then  change 
to  physical  hallucinations  as  the  disease  progresses.  It  is  noteworthy 
that  the  relations  of  the  hallucinations  to  the  ego  are  very  close  in 
schizophrenia  and  in  dreams  and  very  weak  in  alcoholic  insanity  and 
even  in  some  organic  diseases.  Delirious  patients  often  regard  their 
hallucinations  as  a  moving-picture  show.  Another  remarkable  thing  is 
the  fact  that  the  manifestations  in  alcoholic  deliria  are  mostly  colorless, 
while  similar  appearances  in  paresis  and  other  organic  insanities  more 


68  TEXTBOOK  OF  PSYCHIATRY 

frequently  show  color ;  the  patients  speak  of  variegated  butterflies,  red 
powder  spread  all  over,  and  blue  threads.  Hence  the  second  type 
belongs  to  hallucinations  only  insofar  as  its  basic  sensory  stimulus 
originates  in  the  body  itself,  whereas  if  conceived  in  the  pure  psychic 
sense  one  deals  with  simple  illusions. 

Most  of  the  elementary  hallucinations  are  likewise  misinterpreta- 
tions of  irritating  states  of  the  sensory  apparatus,  nevertheless  it  is 
naturally  also  possible  that  the  hallucination  of  shooting,  of  running 
water,  or  lightning  could  sometimes  also  result  from  an  idea. 

2.    DISTURBANCES  OF  CONCEPTS  AND  mEAS 

Persons  who  are  congenitally  blind  or  deaf  mute  naturally  lack  the 
respective  sensory  components  in  their  concepts.  Even  shortsighted 
people  must  perforce  perceive  many  things  somewhat  differently  from 
those  who  have  full  vision.  Some  assume  that  one  cannot  remember 
odors  and  tastes,  still  in  many  persons  such  memory  pictures  form  a 
part  of  the  concepts  of  foods,  flowers,  and  similar  articles  smelt  and 
tasted.  Whether  this  or  that  sense  predominates,  undoubtedly  depends 
largely  on  individual  idiosyncrasy.  In  some  it  is  the  optic  memory'' 
pictures  which  constitute  the  most  important  components  of  their  con- 
cepts and  hence  of  their  thinking,  in  others  it  is  the  acoustic,  and  in 
still  others  it  is  the  motor  memory  pictures.  These  differences  are  of 
importance  in  the  pathology  of  cerebral  localization,  for  a  person 
belonging  to  the  extreme  "visual"  type  having  a  lesion  in  the  occipital 
lobe  is  deprived  of  the  most  important  components  of  his  concepts  and 
hence  sustains  a  greater  loss  in  his  psychic  functions  than  one  of  the 
extreme  "auditif"  type. 

Due  to  a  poverty  of  associations  congenital  defectives  cannot  make 
full  use  of  their  experiences  in  the  formation  of  concepts,  and  conse- 
quently are  less  able  to  connect  and  combine  the  individual  memory 
pictures.  What  is  even  of  much  more  importance  is  the  fact  that  they 
do  not  sufficiently  comprehend  the  concepts  which  others  convey  to 
them  through  speech.  In  this  respect  deaf  persons  are  worse  off,  even 
if  they  are  endowed  with  good  intelligence.  Both  classes  therefore  form 
less  concepts  than  normal  people,  and  they  are  very  apt  to  put  an 
incorrect  limitation  on  them.  They  act  like  little  children  who  may 
put  into  the  same  concepts,  let  us  say,  the  duck  and  the  hornet 
because  both  fly,  and  regard  the  caterpillar  and  butterfly  as  different 
animal  species.  They  also  form  insufficient,  unclear,  and  inaccurate 
limitations;  they  cannot,  for  instance,  distinguish  between  "state"  and 
"country,"  or  even  between  "sparrow"  and  "finch."    These  wrong  and 


GENERAL  PSYCHOPATHOLOGY  69 

insufficient  differentiations  are,  of  course,  much  more  r-ommon  and  more 
profound  in  idiots  than  in  deaf  people,  for  the  former  do  not  note  small 
differences  and  are  unable  to  discriminate  between  essentials  and  un- 
essentials.  Nevertheless  most  concepts  formed  by  idiots  are  not  at  all 
unclear;  this  is  not  only  due  to  the  fact  that  they  form  only  simple 
concepts,  but  chiefiy  because  they  do  not  go  far  from  things  tangible, 
and  form  few  abstract  thoughts. 

However,  there  are  types  of  congenital  defectives,  in  whom  the  most 
essential  deficiency  is  a  lack  of  clearness  in  concept  formation,  but  they 
have  not  as  yet  been  sufficiently  studied.  Thus  an  erethic  imbecile 
defines  the  concept  "valuable"  as:  "When  you  knock  it  higher  (raise 
the  cost),  it  will  cost  even  more."  * 

The  more  complicated  a  concept  and  the  more  remote  its  com- 
ponents are,  the  less  possible  is  it  for  an  imbecile  to  form  or  to  grasp 
the  same;  he  might  in  some  case  understand  the  idea  of  "family"  but 
not  that  of  "state."  However,  it  would  he  incorrect  to  state  that  idiots 
and  imbeciles  form  no  abstract  concepts,  but  it  may  be  said  that  they 
do  not  form  complicated  abstract  ideas,  and  that  frequently  their 
abstract  concepts  are  falsely  construed.  Those  of  a  lower  order  may 
grasp  the  concept  of  "father"  and  "mother,"  but  no  longer  the  concept 
of  "parents";  they  can  thoughtfully  state:  "John  hit  me  and  I  hit 
John,"  but  they  are  unable  to  comprise  this  reciprocal  activity  under 
the  term  "each  other"  or  "one  another." 

Here,  however,  the  difficulties  of  language  must  be  distinguished 
from  those  of  concepts.  This  is  not  always  easy,  even  in  normal  people. 
The  differences  of  personal  disposition,  of  education  and  especially  those 
of  race  are  very  great.  The  disposition  and  education  of  the  French 
is  such,  that  a  schoolboy  there  may  talk  very  nicely  about  things,  of 
which  he  has  at  most  a  very  meagre  understanding.  In  the  German 
part  of  Switzerland  with  its  clumsy  expression,  the  intelligence  of 
foreigners  is  at  first  frequently  overestimated ;  in  our  Swiss  clinic  Ger- 
mans, who  are  more  fluent  in  speech,  are  not  unfrequently  diagnosed  as 
manic  cases,  and  real  manic  patients  often  seem  much  richer  in  concepts 
than  they  are. 

A  good  fluent  speech,  congenital  or  acquired,  often  disguises  real 
deep  defects  of  intelligence,  be  it  in  society,  in  school,  or  even  in  the 
highest  examinations,  which  only  goes  to  show  how  imperfect  these 
organizations  are.  In  such  cases  one  speaks  of  higher  dementia.^  and 
persons  so  afflicted  sometimes  play  a  great  part  in  life.  Thus  a  famous 
"Nature  Healer"  belonging  to  this  category'",  reduced  ever>-thing  to  the 

■"Cf.  Also  below  the  "Nature  Healer"  with  his  "Principle  of  Contrasts." 
°  Cf .  below  Oligophrenia. 


70  TEXTBOOK  OF  PSYCHIATRY 

"Principle  of  Contrasts,"  but  he  could  not  distinguish  between  "con- 
trast" and  "difference,"  between  "power"  and  stimulus,"  between 
"health"  and  "feeling  of  health."  In  more  difficult  matters  such  con- 
fusions of  ideas  may  be  encountered  even  in  the  most  intelligent  class; 
the  frequent  confusions  in  the  deductive  sciences  are  mostly  due  to  the 
fact  that  two  somewhat  differing  concepts  are  connected  by  a  common 
designation  and  are  then  interchanged. 

Thus  one  may  admit,  that  behind  the  properties  of  the  psyche,  there 
must  be  a  carrier  of  the  properties,  a  "being."  But  if  one  then  deducts 
from  the  concept  of  the  "being,"  that  the  psyche  is  punctiform,  lacking 
space  and  time,  one  finds  suddenly  that  instead  of  the  above  concept 
of  the  "being"  or  the  carrier  of  the  observed  psychic  properties,  another 
concept  has  been  substituted,  the  origin  of  which  one  does  not  know  and 
concerning  which  it  must  be  proven  that  it  is  applicable  to  the  relation- 
ships of  the  psyche.  Another  excellent  false  deduction  can  also  be  seen 
in  the  following  reflection:  Cancer  may  be  caused  by  a  cold;  for  all 
physiological  reactions,  hence  also  those  leading  to  cancer  are  con- 
ditioned by  an  "irritant,"  and  cold  is  surely  an  "irritant." 

Symbols  or  concepts  having  one  or  many  common  components,  are 
also  used  by  normal  people,  but  more  so  by  patients.  This  gives  rise  to 
many  coarse  errors  of  thought,  for  instead  of  conceiving  something  as 
a  mere  figure,  it  frequently  takes  the  place  of  the  original  concept, 
thus  the  fire  of  love  is  seen  as  red-hot,  or  the  patient  actually  feels 
it  burning  him. 

In  psychoses,  concepts  may  be  profoundly  distorted.  "Right"  to  a 
litigious  paranoiac  is  usually  what  suits  him,  and  "justice"  becomes 
hypertrophied  in  the  epileptic  patient  who  feels  justified  in  almost 
killing  another  patient,  because  the  other  brushed  against  the  attending 
physician  in  passing.  A  conglomerate  of  concepts,  as  well  as  markedly 
distorted  concepts  are  found  only  in  schizophrenia  and  in  states  of 
clouded  consciousness.  Nevertheless  one  observes  nothing  here  that 
cannot  occasionally  be  found  everywhere  to  a  lesser  extent. 

Many  patients  experience  things  which  are  unknown  to  normal 
persons,  for  which  the  patient  must  create  new  concepts.  Thus  a 
paranoid  praecox  said  that  the  "Double  polytechnic"  is  her  highest 
intelligence  and  accomplishment  which  she  claimed  as  her  due  reward, 
or  another  patient  speaks  of  the  "Dossierpath,"  meaning  the  path  of 
the  hallucinatory  influences.  New  concepts  are  sometimes  created 
through  the  process  of  "condensation"  in  so  far  as  attributes  of  many 
persons  are  fused  in  one. 

The  mental  elaboration  of  concepts  is  frequently  imperfect,  espe- 
cially in  dementia  praecox,  which  causes  temporary  mistakes,  thus 


GENERAL  PSYCHOPATHOLOGY  71 

barrel  and  hoop,  or  even  father  and  mother,  may  be  identified  with 
one  anotlier.  The  boy  who  phiyed  sexually  with  the  patient  in  her 
childhood,  her  lover,  her  seducer,  two  physicians  in  the  asylum  to 
whom  she  transferred  her  love, — all  these  are  thought  of  by  the  patient 
as  one  person.  In  most  of  these  cases  we  do  not  deal  with  a  permanent 
injury.  That  an  advanced  paretic  can  no  longer  think  of  a  compli- 
cated concept  like  "logarithm"  or  even  "state,"  in  its  totality,  is  nat- 
urally the  result  of  a  disturbance  in  his  associations.  Nevertheless,  an 
actual  destruction  of  the  concept  has  not  yet  been  demonstrated  in  the 
psychoses.  If  a  patient  looks  upon  the  attendant  as  his  sister,  it  is 
not  the  result  of  a  disturbance  of  a  concept,  but  it  is  due  to  an  illusion 
or  delusion. 

At  all  events,  the  anomalies  in  the  formation,  retention,  and  in  the 
transformation  of  concepts  have  not  yet  been  sufficiently  studied. 

Disturbances  of  ideas  naturally  exist  insofar  as  the  psychic  proc- 
esses in  general  are  disturbed.  Disturbances  of  perceptions,  of  memory 
pictures,  and  of  the  mental  stream,  must  secondarily  lead  to  disturb- 
ances of  ideas.  Moreover,  it  actually  happens  that  the  specific  quality 
of  ideas  becomes  blurred  by  the  fact  that  the  ideas  become  transformed 
into  hallucinations,  or  they  are  mistaken  for  earlier  experiences. 


3.     DISTURBANCES  OF  ASSOCIATIONS  AND  OF  THOUGHT 

General  Facilitation  of  the  Psychic  Processes.    Flight  of  Ideas. 

Even  normal  persons  who  are  "in  good  humor,"  or  "stimulated" 
sometimes  give  the  subjective  and  objective  impression  as  if  their 
thinking  process  ran  with  particular  ease.  Such  people  have  more  to 
say,  and  sometimes  utter  thoughts  which  are  not  habitual  to  them, 
especially  jokes,  even  quite  daring  ones.  To  be  sure,  such  performances 
cannot  always  stand  the  test  of  criticism.  In  pathological  states, 
mostly  in  connection  with  euphoria  and  exalted  self-reliance,  we  often 
find  a  morbid  exaggeration  of  the  afore-mentioned  state,  which  is 
designated  as  flight  of  ideas.  Here  the  most  striking  phenomenon  is 
the  exaggerated  distractability ,  which  at  first  comes  from  within  but 
later  also  from  without.  The  patients  change  their  objective  idea  with 
abnormal  frequency,  and  in  the  most  serious  cases  it  follows  every 
thought  uttered  or  indicated.  Thus  a  patient  wishes  to  tell  about  a 
trip  to  the  Righi  Mountains  and  he  suddenly  thinks  of  the  donkeys 
which  were  used  there  before  the  construction  of  the  railroad,  then  of 
salami  sausage  supposed  to  be  made  of  donkey  meat  and  then  of  Italy 
where  these  sausages  come  from.    In  less  severe  cases  the  patient  is 


72  TEXTBOOK  OF  PSYCHIATRY 

able  to  revert  to  the  original  theme,  or  he  merges  into  a  thousand  and 
one  things,  being  unable  to  bring  a  single  thought  to  completion.  But, 
except  in  the  most  difficult  cases  where  the  patient's  thoughts  can  no 
longer  be  followed,  or  where  the  intermediate  connecting  thoughts  are 
not  uttered,  one  can  understand  how  thought  is  distracted.  The  sec- 
ondary associations  which  also  appear  in  normal  persons  but  which 
they  suppress,  absorb  the  patient  to  the  same  extent  as  the  principal 
theme. 

The  reenforced  distractability  from  without  may  be  lacking,  but  in 
most  cases  it  is  very  noticeable,  in  so  far  as  every  sensory  impression 
which  impedes  the  flight  of  ideas  is  immediately  elaborated  into  the 
patient's  garrulous  talk.  Thus  seeing  the  doctor's  watch  chain  he 
speaks  about  it,  or  hearing  the  jingling  of  coins  he  immediately  talks 
of  dollars.  This  enhanced  distractability  may  also  be  described  as  a 
disturbance  of  attention  in  the  form  of  hypotenacity  with  hypervigility. 

Both  subjectively  and  objectively  one  gains  the  impression  that  the 
flighty  patients  think  more  rapidly.  However,  the  correctness  of  this 
cannot  be  demonstrated  experimentally.  There  is  no  doubt  that  the 
patient  spends  much  less  than  the  normal  time  on  the  individual  ideas, 
which  also  accounts  for  the  fact  that  they  are  insufficiently  elaborated. 

Thus  flighty  thinking  is  not  aimless  in  content,  although  its  aim  is 
forever  changing.  It  shows  a  preponderance  of  external  and  word 
associations  at  the  expense  of  inner  associations,  which  connect  the 
ideas  according  to  logical  sequence  following  the  actual  mental  trend 
in  the  form  of  associations  of  super-order,  sub-order,  or  causality.^  In 
place  of  inner  associations  there  may  be  accidental  connections,  as 
Salami,  Italy,  instead  of  the  journey  to  the  Righi,  which  do  not  even 
emanate  from  the  sense  of  the  word  but  from  its  sound,  as  seen  in 
association  types  of  rhyme  and  word  completions.  Thus  to  the  word 
"bird"  a  manic  patient  answered:  "Birds  of  a  feather,  flock  together." 

The  following  example  taken  from  the  production  of  a  patient 
showing  flight  of  ideas  will  serve  as  ar^  illustration:  Question,  "Who  is 
the  president  of  the  U.S.?"  "I  am  the  president,  I  am  the  ex-president 
of  the  United  States,  I  have  been  a  recent  president.  Just  at  present  I 
was  present,  president  of  many  towns  in  China,  Japan  and  Europe  and 
Pennsylvania.  When  you  are  president  you  are  the  head  of  all,  you 
are  the  head  of  every  one  of  those,  you  have  a  big  head,  you  are  the 
smartest  man  in  the  world.    I  do  testory  and  all  scientist  of  the  whole 

'  One  of  the  main  headings  in  the  classification  of  associations  is  "Coordina- 
tion" which  includes  associations  of  co-order,  super-order,  sub-order,  or  contrast. 
Examples  of  super-order  are  "fly,"  "insect" — "water,"  "ocean."  E\amples  of 
sub-order  are  "forest,"  "trees" — "animals,"  primates,"  etc.     (Editor.) 


GENERAL  PSYCHOPATHOLOGY  73 

world.  The  highest  court  of  doctoring,  of  practicing,  I  am  a  titled 
lady  by  birth  of  royal  blood  of  rose  blood  (pointing  to  anotlier 
patient) ,  ho  has  black  blood,  yellow  blood,  he  is  no  man,  a  woman,  a 
woe-man,  etc."  " 

The  stimulus  word  "key"  elicited  the  following:  "Oh  you  can 
have  all  the  keys  you  want,  they  broke  into  the  store  and  found  peas, 
what's  the  use  of  keys,  policeman,  watchman,  dogs,  dog  shows,  the 
spaniel  was  the  best  dog  this  year,  he  is  Spanish  you  know,  Morro 
Castle  what  a  big  key  they  have  (refers  to  a  visit  in  Cuba)  Sampson, 
Schley,  he  drowned  them  all  in  the  bay,  gay.  New  York  bay,  Broad- 
way, the  White  Way,  etc."  ^ 

One  can  always  note  a  weakness  in  the  patient's  reflection  and 
judgment.  Even  if  they  bring  to  the  surface  some  ingenious  thought 
and  are  able  to  utter  truths  which  would  not  occur  to  normal  persons 
or  which  they  would  suppress,  such  productions  are  in  most  cases 
extremely  superficial  in  judgment,  they  are  one  sided  and  hasty,  and 
are  deficient  in  some  of  the  necessary  factors.  Wherever  the  choice  of 
impressions  and  ideas  are  inadequate  there  is  also  a  lack  in  orderly 
arrangement.  Whenever  one  gets  the  impression  that  the  patient's 
achievements  are  above  the  average  it  is  usually  due  to  cessation  of 
inhibition  and  not  to  an  acceleration  of  his  mental  facilities.  The 
average  person  cannot  say  some  things,  he  cannot  even  think  of  them, 
because  of  consideration  for  others  or  himself  or  because  an  inner 
critique  keeps  him  back,  the  flighty  patient,  however,  ignores  such 
reflections  or  they  never  occur  to  him,  he  knows  no  embarrassment. 

Sometimes,  especially  before  merging  into  a  depression  or  into  a 
manic  depressive  mixed  state,  the  patients  firmly  adhere  to  an  apparent 
aim  but  leave  out  all  logical  connections.  Such  persons  limit  their 
productions  to  a  series  of  names  of  persons,  places,  offices,  etc.,  some 
individual  parts  of  which  besides  being  linked  through  the  general 
superordination  of  the  ideas,  are  also  associated  through  sound 
similarities. 

Flight  of  ideas  is  an  essential  component  of  the  manic  symptom- 
complex.  Similar  mental  disturbances  also  occur  in  exhaustion  and 
perhaps  also  in  toxemias.  In  all  probabilities  there  are  distinctions 
between  the  individual  forms,  but  we  do  not  know  them  as  yet. 

Flight  of  ideas  does  not  represent  a  simple  acceleration  of  associa- 
tions. Liepmann  endeavored  to  explain  it  on  the  basis  of  a  disturbance 
of  attention,  but  one  gains  nothing  by  it  as  one  can  just  as  lief  reason 
the  other  way  and  explain  disturbances  of  attention  through  flight  of 

'  Giv^en  by  editor. 
*  Given  by  editor. 


74  TEXTBOOK  OF  PSYCHIATRY 

ideas.  We  might  venture  the  following  conception:  Regulated  thinking 
is  conditioned  by  the  fact  that  the  hierarchy  of  the  leading  thoughts 
inhibit  all  ideas  not  belonging  to  the  theme.  As  we  must  also  assume 
in  other  cases,  the  inhibiting  resistance  obtruding  itself  is  relative  in 
its  action.  As  intrapsychic  functions  are  only  too  easily  stimulated  in 
manic  patients — the  patients  feel  a  bubbling  over  of  thoughts— the 
stimulus  threshold  seems  smaller  and  the  relation  between  inhibition 
and  function  is  disarranged.  In  view  of  all  that,  the  resistance  exerted 
by  the  leading  thought  no  longer  suffices  to  inhibit  associations  which 
are  unrelated  to  it. 

Melancholic  Retaedation  of  Associations  (Inhibition) 

A  retardation  of  the  train  of  thought,  already  noticeable  in  sad 
normal  persons,  is  present  in  cases  of  morbid  depressions;  the  entire 
process  of  thought  proceeds  slowly  and  in  a  laboriously  subjective 
manner.  It  is  difficult,  and  often  impossible  for  the  patients  to  change 
the  idea  controlling  them;  this  preferred  idea  deals  with  their  imag- 
inary misfortune  (monideism) .  The  patients  are  frequently  aware  of 
their  poverty  of  ideas  and  perceive  it  as  dreary  and  monotonous.  Ideas 
which  are  incompatible  with  the  depressive  thoughts  can  be  touched 
upon  with  difficulty  or  not  at  all;  so  that  judgment  becomes  consider- 
ably warped  and  the  development  of  delusions  is  made  quite  easy.  On 
superficial  observation  the  patients  sometimes  even  give  the  impression 
of  feeble-mindedness. 

Associations  in  Organic  Psychoses 

The  number  of  individual  concepts  simultaneously  available  to 
patients  suffering  from  organic  psychoses  is  less  than  in  normal;  this 
can  be  most  readily  demonstrated  when  the  patients  attempt  to  do 
examples  in  arithmetic.  Whereas  normally  the  patients  were  able,  for 
instance,  to  do  mentally  an  addition  of  four-digit  numbers,  they  can 
now  only  add  one  one-digit  number  to  a  two-digit  number  without  for- 
getting the  problem.  The  characteristic  restrictions  of  organic  disturb- 
ances is  shown  by  the  fact  that  the  selection  as  well  as  the  rejection  of 
associations  occurs  mainly  in  the  sense  of  the  affective  trend.  Where- 
ever  it  is  primarily  a  question  of  affects  or  impulses,  the  associations 
antagonistic  to  the  particular  impulse  are  left  out.  As  examples  of 
this,  one  may  cite  the  former  morally  senile  patient,  who,  in  a  state 
of  sexual  excitement  sees  only  the  female  in  the  child  and  abuses  it 
sexually,  or  the  paralytic  who  steals  some  tempting  object  under  the 
eyes  of  a  few  dozen  spectators  and  conceals  it  under  his  clothing,  or 
the  paretic  who  jumps  out  of  an  upper  story  window  in  order  to  pick 


GENERAL  PSYCHOPATIIOLOGY  7o 

up  a  fallen  cigar-stump  (Kraepclin).  A  senile  patient  is  capable  of 
praising  his  mother  as  a  saint  and  immediately  thereafter  merge  into 
another  constellation  and  have  nothing  but  evil  to  tell  about  her. 

This  restriction  of  thought  for  the  time  being  to  a  specific  cluster 
of  ideas —physically  speaking,  is  like  an  attempt  to  get  one's  bearings 
through  a  key-hole, — exposes  the  patients  to  the  danger  of  committing 
great  stupidities;  they  enter  into  business  undertakings  without  con- 
sidering risks,  they  contract  foolish  marriages,  or  commit  similar 
foolish  acts. 

When  only  a  few  ideas  can  be  grasped  simultaneously,  an  orderly 
arrangement  of  them  becomes  difficult.  Thus  a  patient  states  that  he 
was  born  in  1872,  he  knows  that  it  is  now  1917,  but  nevertheless  thinks 
that  he  was  62  years  old  ten  years  ago.  He  comes  to  this  conclusion 
by  subtracting  10  from  72  instead  of  from  his  present  age.  The  co- 
ordinating associations  as  such  may  also  be  affected.^ 

Furthermore,  a  restriction  of  associations  may  also  be  due  to  the 
fact  that  especially  senile  patients,  and  less  so  paralytics  and 
Korsakoff  patients,  become  more  and  more  egocentric  and  are  par- 
ticularly fond  of  concerning  themselves  with  their  own  pleasures  and 
woes,  often  in  a  very  petty  fashion.  Nevertheless,  they  are  much 
more  capable,  than,  for  instance,  organic  epileptics,  of  occupying  them- 
selves with  other  things,  in  so  far  as  they  can  still  grasp  them.  They 
are  especially  capable  of  showing  a  very  affective  and  exaggerated 
interest  in  the  affairs  of  their  friends  and  enemies.  In  conversation 
the  patients  find  it  difficult  to  pass  from  one  thought  to  another.  Even 
in  cases  where  primary  comprehension  is  still  quite  good,  they  answer 
to  a  question  which  does  not  exactly  belong  to  the  particular  subject, 
frequently  they  answer  only  after  numerous  repetitions,  or  in  the  sense 
of  the  former  trend  of  thought.  It  thus  often  happens  that  they  still 
continue  to  give  information  about  personal  matters  when  that  topic 
has  long  been  finished  and  when  the  question  may  refer  to  their 
education. 

Besides  those  mentioned  there  are  other  mechanisms  which  often 
prevent  the  patients  from  leaving  an  idea.  Thus  in  an  association  test 
they  will  repeat  again  and  again  an  accidental  reaction  word,  and  in 
a  perception  test  they  will  call  a  penholder  a  cow,  if  the  picture  of 
such  an  animal  has  previously  been  shown  them  [perseveration). 

The  duration  of  time  of  associations  in  organic  patients  is  retarded 

in  most  cases.    This  is  especially  seen  in  cases  of  senility,  where  one 

sees   additional   accessory  processes,  which   hamper   and  retard   the 

psychic  processes,  such  as  cerebral  pressure  and  other  phenomena  that 

"  Cf.  also  "Orientation,"  p.  32. 


76  TEXTBOOK  OF  PSYCJIIATRY 

are  not  yet  well  understood.  Retardation  shows  itself  with  especial 
regularity  in  experimental  associations;  but  in  such  cases  difficulty 
of  comprehension  may  play  a  part.  Here  the  associations  are  emo- 
tionally accentuated,  very  closely  related,  and  contain  many  lepeti- 
tions,  partly  due  to  perseveration  of  ideas,  and  partly  to  poverty  of 
thought.  The  patient  finds  it  difficult  or  impossible  to  restrict  the 
reaction  to  a  single  word. 

A  diagnosis  can  frequently  be  made  in  a  few  moments  from  the 
continuous  associations  showing  the  garrulous  organic  type,  which 
would  have  been  impossible  to  do  before,  when  nothing  characteristic 
could  be  sufficiently  emphasized  in  the  description  of  the  case.  In 
most  cases  it  is  a  question  of  a  slow  progress  of  the  course  of  ideas 
with  a  tendency  to  repetitions.  The  utterances  often  express  a  pro- 
nounced affect  in  its  content,  which  is  even  more  marked  by  its  em- 
phasis. Sometimes  one  hears  nothing  but  wailing  or  boasting,  with 
or  without  a  definite  theme.  It  is  through  the  emotional  accentuation 
rather  than  through  the  greater  mobility  and  better  intellectual 
coherence,  that  such  out-pourings  are  distinguished  from  the  lamenta- 
tions of  depressive  Schizophrenic  cases,  whose  affective  expressions, 
even  when  present,  hardly  ever  conceal  a  pronounced  rigidity.  Typical 
associations  may  be  seen  in  the  following: 

"My  dearest  Doctor,  "I'm  all  wrong,  O  God  in  Heaven  have  pity 
on  me.  Father  in  Heaven  be  compassionate.  Dear  good  Doctor,  help 
me.  Let  me  out.  Heavenly  father,  please  don't  forsake  me.  I'm  not 
capable  of  that.  Why,  I'm  quite  right  in  my  mind.  Will  you  please 
take  pity.  I  can't  do  anything  else,  0  dearest  God.  No,  no,  no,  I 
must  go  away,  do  be  merciful.  Doctor,  won't  you  be  merciful?  0 
Jesus  Christ,  take  pity  on  me.  There  is  something  the  matter  with 
every  inch  of  me.  My  judgment  is  wrong.  There  is  nothing  else  that 
is  important.  Have  pity  on  my  sinful  self,  0  Doctor,  do  forgive  me 
once  more." 

Experimental  associations  ^°  are  very  characteristic  in  the  more 
pronounced  cases;  if  there  is  no  question  of  epilepsy,  which  exhibits 
similar  peculiarities,  the  associations  alone  are  often  sufficient  to  make 
the  diagnosis.  All  reactions  are  retarded.  The  impoverishment  of 
ideas  manifests  itself  very  clearly  in  reactions  that  are  not  far  removed 
from  the  test  word,  and  in  generalities,  thus  the  stimulus  word  "green," 
gives  the  reaction,  "It's  everywhere;  green — the  green  outside."  As  in 
oligophrenic  cases,  a  large  number  of  the  reactions  consist  in 
tautologies,  definitions,  designations  of  places,  and  the  like.    But  even 

^''  Brunnschweiler,    Ueber    Assoziationen    bei    organisch    Deraenten.      Ziiricher, 
Diss.  1912. 


GENERAL  PSYCHOPATHOLOGY  77 

these  tend  readily  to  be  blurred,  thus  the  word  "family"  is  reacted  to 
with  "Something  in  the  house  there."  Educated  patients  get  around 
their  poverty  of  ideas  by  means  of  near-by  association  of  words.  The 
perseveration  tendency  often  strongly  preponderates.  The  affectivity 
shows  itself  in  many  reactions  as  in  epileptic  cases,  but  with  a  much 
lower  valuation,  sometimes  it  evinces  itself  in  just  bare  interjections: 
Righto — Oho!  righto;  or  table — what-the-dcuce.  Complexes  show 
themselves  directly  and  without  repression.  Egocentric  reactions  occur 
frequently,  and  are  said  to  be  quite  banal,  particularly  in  paralytic 
cases,  thus,  "bad," — "I  don't  know  of  anything  bad,"  and  to  consist  of 
reminiscences  of  former  experiences  in  senile  cases,  thus:  "mountain," 
— "I  was  once  at  Horgen  mountains,  from  there  I  had  to  go  home 
from  the  barracks  on  foot."  As  has  been  mentioned,  when  the  disease 
has  reached  a  certain  stage,  organic  cases  are  no  longer  capable  of 
answering  with  a  single  word,  they  cannot  isolate  the  concept,  they 
must  tell  the  whole  idea,  or  the  thing  which  affects  them. 

The  associations  of  states  of  organic  confusion  have  not,  as  yet, 
been  the  subject  of  sufficient  research.  But  one  can  often  recognize 
even  in  the  confusion  the  described  type  of  the  actual  disease. 

Schizophrenic  (Dreamlike)  Disturbances  of  AsoOciation 
(Zerfahrenheit  of  Kraepelin) 

Whereas  the  empirically  acquired  structures  of  associations  are 
not  loosened  in  flight  of  ideas  and  impediment  of  thought  as  well  as 
in  organic  disturbances  of  associations,  their  effectiveness  is  restricted 
in  schizophrenia.  Neither  a  manic  patient,  nor  a  sound  person  thinks 
of  modern  Italy  at  the  mention  of  the  name  of  Brutus.  But  a  schizo- 
phrenic, by  disregarding  the  component  of  time  connected  with  the 
term,  can  call  the  Roman  an  "Italian,"  or  he  can  designate  the  location 
of  Egypt  as  "between  Assyria  and  the  Congo  State,"  by  again  ignoring 
the  periods  to  which  each  of  the  states  belong,  and  at  the  same  time 
exchanging  in  a  most  bizarre  manner  the  most  immediately  obvious 
place  designation  (say,  "the  Northeast  of  Africa")  for  one  altogether 
peculiar. 

Although  the  following  two  productions  lack  clear  objectivity  the 
patients  nevertheless  stick  almost  perfectly  to  the  theme  which  happens 
to  refer  to  ancient  history  narrative  of  the  Orient.  The  individual 
associations  seem  accidental  or  stimulated  through  sound  or  other 
factors  foreign  to  a  normal  person.  They  differ  from  flight  of  ideas 
through  the  fact  that  a  normal  person  can  understand  the  individual 
steps  of  the  latter,  whereas  many  steps  that  are  made  in  a  schizophrenic 
train  of  thought  are  unintelligible  to  the  normal  person,  or  appear  to 


78  TEXTBOOK  OF  PSYCHIATRY 

be  so  bizarre,  that  they  would  never  have  entered  his  mind.     The 
following  examples  will  serve  as  illustrations: 

"Epaminondas  was  one  who  was  powerful  especially  on  land  and 
sea.  He  was  the  leader  of  great  fleet  manoeuvers  and  open  sea-battles 
against  Pelopidas,  but  had  been  struck  on  the  head,  during  the  second 
Punic  war,  because  of  the  wreck  of  an  armored  frigate.  He  wandered 
with  ships  from  Athens  to  Hain  Mamre,  took  Caledonian  grapes  and 
pomegranates  and  overcame  Bedouins.  He  besieged  the  Acropolis  with 
gun-boats,  and  caused  the  Persian  crew  to  be  burnt  as  living  torches. 
The  subsequent  pope  Gregory  VII — eh — Nero  followed  his  example 
and  because  of  him  all  Athenians,  all  Roman-Germanic-Celtic  races, 
towards  whom  the  priests  were  not  favorably  disposed,  were  burned  at 
the  hands  of  the  Druids  as  an  offering  to  the  Sun-god  Baal  on  Corpus- 
Christi  Day.  This  is  the  period  of  the  Stone  Age.  Spear-points  of 
Bronze."     (Stenographically  recorded.) 

The  Blossom-Time  for  a  Horticulturist 

"At  the  time  of  the  New-Moon  Venus  stands  in  the  August  heavens 
of  Egypt  and  with  its  rays  of  light  illuminates  the  harbors  of  commerce, 
Suez,  Cairo,  and  Alexandria.  In  this  historically  famous  city  of  the 
Kalifs,  there  is  situated  in  the  museum  of  Assyrian  monuments  from 
Macedonia.  There  plantain  flourishes  next  to  maize  columns,  oats, 
clover,  and  barley,  also  bananas,  figs,  lemons,  oranges,  and  olives. 
Olive-oil  is  an  Arabian  liqueur-sauce,  with  which  Afghans,  Moors, 
and  Moslemites  carry  on  the  breeding  of  ostriches.  The  Indian  plan- 
tain is  the  whiskey  of  the  Parsee  and  of  the  Arab.  The  Parsee  or 
the  Caucasian  possesses  exactly  as  much  influence  over  his  elephant 
as  the  Moor  has  over  his  dromedary.  The  camel  is  the  sport  of  the 
Jew  and  the  Indian.  In  India,  barley,  rice,  and  sugar-cane,  that  is, 
artichoke,  flourish  luxuriantly.  The  Brahmins  live  in  castes  on 
Beluchistan.  The  Circassian  inhabit  Manchuria  of  China.  China 
is  the  Eldorado  of  Pawnees."     ("Letter  of  a  Schizophrenic") 

The  association  is  sometimes  formed  as  a  result  of  factors  from 
without  even  when  there  is  not  the  slightest  real  connection.  Thus 
the  patient  explains  his  violent  action  on  the  ground  that  "the  at- 
tendant wears  a  white  apron,"  only  because  the  attendant  happens 
to  be  standing  near  when  the  question  is  asked. 

Not  at  all  infrequently  new  ideas  crop  up  which  have  no  connec- 
tion of  any  kind  with  what  has  gone  before,  sometimes  the  patient 
states  that  they  "flashed"  through  his  mind  but  at  other  times  he  does 
not   recognize   anything   abnormal   about  them.     If   the   last-named 


GENERAL  PSYCHOPATHOLOGY  79 

mechanism  repeatedly  recurs,  the  mental  stream  becomes  "distorted" 
and  finally  coherence  disappears  altogether.  The  individual  thoughts 
then  have  no  connection  with  one  another  from  the  point  of  view  of 
the  observer,  and  in  most  cases  also  from  that  of  the  patient.  Indeed, 
it  not  infrequently  happens  that  the  patient  never  produces  any 
coherent  thought,  as  the  concepts  are  piled  together  without  any 
logical  connection. ^^ 

The  separation  of  associations  from  experience  naturally  facilitates 
dereistic  thinking  in  the  highest  degree,  which  is  actually  based  on 
the  very  fact  that  natural  connections  are  ignored.  Without  the 
slightest  regard  for  real  and  logical  possibilities,  the  faintest  wishes 
and  fears  are  endowed  with  the  subjective  reality  of  the  delusion. 
The  most  usual  secondary  associations,  vague  analogies  and  accidental 
connections  determine  the  train  of  thought.  Dereistic  thinking  is 
usually  quite  unrestricted  in  dreams  because  the  latter  are  actively 
disbarred  from  the  outer  world  while  in  schizophrenia  it  proceeds  at 
a  mad  rate  mixed  with  correct  and  realistic  directives. 

In  the  schizophrenic  course  of  thought  one  observes  the  most  varied 
disturbances.  Of  particular  importance  are  the  obstructions  where 
the  mental  stream  suddenly  ceases  remaining  away  from  seconds  to 
days  ('Thought  deprivation").  When  the  obstruction  is  over,  a  new 
thought,  which  had  no  connection  with  the  one  preceding  obstruction, 
frequently  crops  up. 

The  distinction  between  obstruction  and  inhibition  is  ver>^  impor- 
tant; the  latter  signifies  depression,  the  former  (with  the  reservation 
stated  below)  Schizophrenia;  superficially,  however,  the  two  symptoms 
resemble  very  much. 

In  profound  disturbances  the  reactions  to  both  anomalies  are  alto- 
gether or  almost  completely  reduced  to  zero.  But  even  when  impeded, 
patients  attempt  to  answer,  the  obstructions,  particularly  in  acute 
cases,  in  order  to  express  themselves  in  motion  can  usually  be  over- 
come only  by  strong  and  persistent  effort,  and  even  then  the  patient 
can  only  produce  feeble  and  slow  motions  and  utter  words  in  a  low 
tone.^^  In  most  cases,  however,  the  two  kinds  of  disturbances  can 
easily  be  differentiated,  inasmuch  as  impeded  patients  can  react  just 
as  quickly  and  strongly  as  sound  persons,  once  the  obstruction  has 
been  broken  down,  whereas  inhibited  patients  always  evince  the  re- 

"  Cf.  below,  "Confusion,"  also  the  additional  details  about  schizophrenic 
thinking  in  the  chapter  on  "Schizophrenia:  Condensations,  Displacements,  and 
Symbols." 

"In  such  cases  it  is  probably  not  a  question  of  simple  obstruction,  but  rather 
of  a  combination  with  a  third  form  of  retardation  of  the  psychic  processes, 
which  we  cannot  yet  emphasize  (swelhng  processes  of  the  brain,  etc.). 


80  TEXTBOOK  OF  PSYCHIATRY 

tarded  character  of  their  movements.  (If  the  difference  does  not 
manifest  itself  in  spontaneous  expressions,  the  patients  can,  for  in- 
stance, be  asked  to  count  to  twenty  as  quickly  as  possible,  or  to  turn 
their  hands  quickly  one  about  the  other.) 

The  obstruction  may  be  compared  to  the  closing  of  a  valve  in  a 
piping  system  carrying  a  highly  mobile  fluid,  while  the  inhibition  is 
analogous  to  a  slowing-up  of  the  flow  as  the  result  of  increasing 
viscosity  of  the  fluid.  The  obstruction  is  a  sudden  stoppage  of  psychic 
processes  caused  by  affective  disturbances,  and  in  itself  is  not  a  patho- 
logical manifestation.  Some  affects  bring  to  a  standstill  thoughts  and 
actions  even  in  normal  persons  ("examination  stupor,"  or  "emotional 
stupor").  Pronounced  obstructions  may  therefore  be  observed  in  all 
nervous  and  particularly  in  hysterical  patients.  In  those  cases,  how- 
ever, where  they  are  not  sufiiciently  determined  psychologically,  where 
they  become  generalized,  or  last  unduly  long,  their  presence  justifies 
the  diagnosis  of  schizophrenia. 

In  neuro-physiology,  such  stoppages  of  one  function  through  an- 
other are  designated  as  "inhibitions"  while  in  psychopathology,  the 
primary  meaning  of  the  word,  as  the  above  historical  considerations 
have  shown,  is  something  altogether  different,  it  signifies  the  general 
retardation  of  thought  processes  in  melancholic  conditions.  There  are, 
to  be  sure,  still  other  general  retardations  of  the  psychic  processes  for 
which  we  have  not  yet  any  special  designation  because  we  have  no 
adequate  knowledge  of  them.  Many  are  named  in  accordance  with 
their  causes,  as  schizophrenic  swelling  of  the  brain,  brain  pressure  in 
general,  toxic,  epileptic  disturbances,  and  brain-torpor.  In  another 
connection  "inhibitions"  are  spoken  of  in  a  moral  sense,  thus  a 
psychosis,  or  alcohol  destroys  the  inhibitions  connected  with  wrong 
actions.  Here  again  the  meaning  of  the  expression  tends  towards  its 
usual  physiological  significance. 

In  superficial  contradistinction  to  obstruction,  schizophrenics  often 
feel  a  "crowding  of  thoughts";  they  are  forced  to  think.  In  such 
cases  the  content  subjectively  seems  rich  and  varied,  and  gives  the 
impression  of  a  continuous  mental  stream.  But  if  the  attempt  is  made 
to  penetrate  a  little  more  deeply,  one  regularly  gets  the  impression 
that  the  patients  are  forced  to  think  always  the  same  thoughts.  The 
crowding  of  thoughts  is  in  most  cases  connected  with  a  disagreeable 
feeling  of  exertion.  The  feeling  of  activity  may,  however,  also  be 
lacking;  "something  thinks"  in  the  patients,  or  "some  one  makes  them 
thoughts." 

Crowding  of  thoughts  is  distinguished  from  obsessive  ideas  by  the 
fact  that  in  the  former  the  obsession  lies  in  the  subject-matter,  while 


GENERAL  PSYCHOPATHOLOGY  81 

in  the  latter,  it  is  in  the  process.  The  compulsive  patient  cannot  rid 
himself  of  an  apprehension  or  of  an  impulse,  but  in  the  schizophrenic 
it  is  the  thinking  function  itself  which  is  perceived  as  an  automatism 
or  compulsion,  quite  independent  of  the  content,  which  can  be  prin- 
cipally varied  in  any  way. 

Furthermore,  the  thoughts  may  run  too  rapidly,  as  in  the  case  of 
flight  of  ideas,  or  they  may  be  inhibited.  Such  complications  naturally 
occur  regularly  whenever  manic  and  melancholic  states  develop  in 
schizophrenic  soil,  which  happens  quite  frequently.  In  such  circum- 
stances flight  of  ideas  or  depressive  inhibition  is  mingled  with  the 
specific  disturbance  of  the  associations.  The  schizophrenic  lack  of 
concern  about  the  aim  of  the  thought  naturally  shows  in  some  cases 
frequent  manifestations  which  cannot  in  themselves  be  distinguished 
from  flight  of  ideas.  The  inhibition  occasionally  causes  the  observer 
to  mistake  it  for  brevity  of  associations,  wnich  in  most  cases  belongs 
directly  to  schizophrenia  and  consists  in  the  fact,  that  the  number  of 
available  concepts  diminish  and  consequently  the  mental  stream  is 
always  equally  ready  or  "brief."  ^^ 

This  is  seen  in  important  as  well  as  in  unimportant  trends  of  ideas. 
When  the  patient  is  asked  to  relate  a  fable  which  he  has  read,  he  is 
unable  to  proceed  beyond  the  next  step  in  the  story,  unless  he  is  given 
an  additional  prod.  When  asked  to  tell  about  his  divorce,  he  at  first 
knows  nothing  except:  "I  am  divorced."  "Why  are  you  divorced?" 
"She  ran  away  from  me."  "Why?"  "V/e  did  not  get  along."  "Why." 
"Because  of  a  child,"  etc. 

Pathological  brevity  of  associations  is  to  be  distinguished  from  a 
similar  quality  in  persons  who,  for  some  reason  or  another,  are  not 
willing  to  give  information. 

In  schizophrenia  we  often  find  a  special  kind  of  perseveration, 
which,  to  be  sure,  we  are  not  yet  able  to  describe  as  regards  its  specific 
peculiarities,  although  we  must  assume  that  it  differs  from  other  forms. 
Accidental  psychic  processes,  thoughts,  and  actions  may  become 
stereotyped;  an  idea  is  repeatedly  thought  and  expressed  in  all  varia- 
tions and  connections,  it  is  "worked  to  death."  Stereotyped  habits 
are,  above  all,  formed  by  emotionally  accentuated  complexes  (see 
"stereotypes"). 

Schizophrenic  and  dream-like  disturbances  of  association  may  be 
hypothetically  traced  to  the  same  origin:  As  sleep  and  disturbances 
of  attention  deflect  the  associations  from  their  customary  paths,  it 
may  be  assumed,  that  a  certain  force  is  necessary  to  keep  associations 
in  the  track  laid  out  by  experience.     Now  it  is  possible  that  this  force 

m;        ''CLp  85. 


82  TEXTBOOK  OF  PSYCHIATRY 

or  "control-tension"  has  also  been  diminished  or  hampered  in  its  action 
because  of  the  fundamental  schizophrenic  process.^* 

Associations  of  Oligophrenics 

The  train  of  ideas  of  imbeciles  and  idiots  is  restricted.  But  in 
contrast  to  organic  impoverishment  of  associations,  it  is  not  the  ob- 
jective idea  that  determines  here  the  choice  of  the  reduced  psychic 
material.  The  ideas  which  are  left  out  are  those  which  are  uncom- 
mon, and  do  not  originate  from  the  immediate  sensory  perceptions,  or 
those  which  are  more  complicated  and  do  not  belong  to  every  day 
experience.  The  imbecile  does  not  forget  that  he  can  get  hurt  by 
jumping  out  of  a  high  window,  but  he  might  have  an  accident  as  a 
result  of  climbing  down  a  trellis-work  whose  carrying  strength  he  over- 
estimates. An  imbecile  described  by  Wernicke  was  driving  a  wagon 
which  struck  a  rock  and  therefore  could  go  no  farther.  He  thereupon 
whipped  the  horses  instead  of  driving  around  the  rock;  the  act  of 
resorting  to  the  whip  when  the  wagon  will  go  no  farther  is  really  the 
habitual  thing  to  do,  while  it  happens  only  rarely  that  there  is  need 
for  driving  around  an  obstacle  lying  in  the  middle  of  the  street. 
Within  particularly  easy  reach  and  at  the  same  time  easily  stimulated 
are  those  ideas  which  concern  the  ego.  That  is  to  say,  they  belong  to 
those  ideas  which  are  most  easily  thought  of,  a  fact  which  gives  rise, 
in  imbeciles,  to  a  sort  of  egocentricity,  which  is  further  strengthened 
by  the  lack  of  understanding  for  the  matters  which  concern  others.^^ 

Associations  of  Epileptics 

For  obvious  reasons  (concomitant  congenital  weakness  plus  cerebral 
atrophy)  the  associations  of  epileptics  often  show  disturbances  similar 
to  those  of  imbeciles  and  organic  cases  but  in  addition,  they  present 
the  specific  epileptic  signs,  which  are  so  characteristic  that  they  furnish 
the  material  for  diagnosis  in  cases  that  are  more  or  less  pronounced. 
Nevertheless,  the  line  of  demarkation  from  the  organic  cases  is  not 
yet  sufficiently  distinct.  The  abnormities  which  show  themselves  most 
clearly  in  the  experimental  associations  are  as  follows:  the  answers 
come  very  slowly,  the  patients  find  it  difficult  to  respond  with  a  single 
word  and  they  frequently  employ  whole  sentences  that  are  often  very 
indistinct,  containing  peculiar  and  tortuous  expressions.  The  content 
is  poor  in  ideas  showing  tautologies,  meaningless  definitions,  and  the 

"  Bleuler,    Storung    der    Assoziationsspannung,    ein    Elementarsymptom    der 
Schizophrenien  Allgem.  Zeitschr.  f.  Psychiatrie  1918.    P.  1. 
^''  For  more  details  see  the  chapter  on  oligophrenia. 


GENERAL  PSYCHOPATHOLOGY  83 

like,  and  contains  many  affective  designations  among  which  one  fre- 
quently finds  opinions  of  value,  such  as  good,  beautiful,  just,  "one 
should,"  and  moral  tendencies.  Another  mechanism  observed  is 
that  of  perseveration,  not  so  much  in  the  sense  that  the  patient  gets 
stuck  to  a  reaction,  but  a  word,  a  phrase  or  sentence  form  once  used 
easily  crops  up  again  later  on.  The  entire  circle  of  ideas  gradually 
becomes  more  and  more  completely  narrowed  down  to  the  patient's 
own  ego. 

Examples:  Poverty  of  ideas  manifests  itself  among  other  things 
in  senseless  associations,  continued  grammatical  constructions,  tautolo- 
gies, and  the  like;  thus,  long — is  not  short;  loved — what  one  likes  is 
also  loved;  heart — people;  beat— people;  sacrifice — there  are  all  kinds 
of  sacrifices;  wonder — to  wonder.  Egocentric  relations:  wish — health; 
naturally — one  would  rather  be  well  than  sick;  time — I  would  gladly 
spare  it,  for  the  sake  of  good  fortune.  Examples  of  emotional 
emphasis  and  affective  valuation:  greenish — is  a  pretty  color;  sweet — 
is  good;  to  part — is  not  beautiful;  youth — joy;  to  strike — evil  persons 
strike.  Clumsy  and  obscure  circumstantial  expressions:  luck — joy  ful- 
ness or  something  like  that."  Wrath — man  is  wrathful. ^^  Flower — 
the  flower  belongs  to  the  trimmings  of  the  window-plants  in  the  dwell- 
ings of  people,  isn't  that  so?  ^*  point — one  can  make  a  point,  what  one 
does  in  business,  if  a  stone  is  made,  or  something  else  ^^  (wishes  to  say 
something  to  the  effect  "sharp  stone") . 

A  type  of  perseveration  also  occurs  with  great  frequency  in  ordi- 
nary conversation  and  shows  itself  in  the  fact  that  patients  can  hardly 
get  away  from  an  idea.  They  repeat  themselves  word  for  word  or  in 
tautologies,  they  use  circumstantial  modes  of  expression,  they  present 
a  multitude  of  non-essential  trifles  and  trivialities,  but  they  do  not 
lose  their  goal,  nor  can  they  be  diverted  from  their  snail-like  paths 
by  being  requested  that  they  come  to  the  point.  Indeed  the  distract- 
ability  of  epileptics  is  abnormally  slight.  The  circumstantiality  of 
their  thinking  is  sometimes  also  reflected  in  their  actions  and  their 
entire  behavior. 

Whereas  a  sound  person  will,  so  to  speak,  sit  down  in  one  con- 
tinuous movement,  many  an  epileptic  finds  it  necessary  to  perform 
this  act  in  the  following  manner:  He  first  places  the  chair  in  a  special 
position,  then  he  considers  his  spatial  relation  to  the  chair,  then  he 
proceeds  to  place  himself  in  the  proper  attitude  towards  the  same,  and 

^^  Fuhrmann,  Analyse  des  Vorstellungsmaterials  usw.  Diss.  Giesen,  1902. 

"  Ihid. 

^^Holzinger,  Assoz.  Versuche  bei  Epilepsie.    Diss.  Eriangen,  1908. 


84  TEXTBOOK  OF  PSYCHIATRY 

thereupon  he  must  arrange  his  clothes  accordingly,  as  for  example, 
he  must  draw  apart  his  coat-tails,  and  now  at  last  he  can  sit  down 
in  a  sprawling  attitude. 

In  speech  one  is  frequently  struck  by  a  momentary  hesitancy  or 
stalling;  in  such  cases  the  patients  often  repeat  a  syllable  several  times, 
and  then  they  proceed  further.  This  symptom  is  obviously  the  ex- 
pression of  a  hesitating  train  of  thought;  it  is  as  though  there  were 
resin  in  a  machine,  which  often  brings  it  to  rest  for  a  few  moments 
and  then  lets  it  move  again. 

The  intensity  of  these  symptoms  generally  runs  parallel  to  the 
degree  of  dementia;  although  it  varies  very  much  even  in  the  same 
patients  and  is  especially  pronounced  after  attacks  and  in  twilight 
states. 

The  additional  part  noticed  in  twilight  states  has  not  yet  been 
characterized.  In  some  cases  the  main  element  shows  itself  in  an 
enormous  exaggeration  of  the  described  peculiarities,  in  other  cases 
there  seems  to  be  added  something  new,  which  has  been  incorrectly 
designated  as  incoherence. 

The  Associations  of  Hysteria 

The  associations  of  hysteria  are  under  the  pronounced  domination 
of  the  affects.  Even  in  the  habitual  states  the  experiment  shows 
irregular,  often  very  high-graded  prolonged  reaction-times,  indeed, 
sometimes  no  answer  can  be  elicited,  in  content  the  associations  are 
superficial  and  psycho-galvanic  phenomena  are  very  high.^*'  Actual 
affects  cloud  the  logic  in  hysterical  patients  to  a  very  high  degree. 
That  which  was  today  praised  to  heaven  may  be  painted  with  coal- 
black  colors  tomorrow  for  just  as  many  opposing  reasons.  In  the 
hj'^sterical  twilight  state  reality  is  systematically  side-tracked  and  an- 
other dream-world  is  created  to  replace  it;  this  is  helped  by  falsifica- 
tions of  logic  and  sensory  deceptions. 

Associations  of  Neurasthenics 

In  the  association  test  with  neurasthenics  it  is  remarkable  that 
they  often  answer  to  the  test-word  instead  of  to  its  meaning,  they 
behave  just  like  patients  who  suffer  from  acute  exhaustion.  For  the 
rest  their  associations  have  not  yet  been  sufficiently  studied  and  can 
just  as  little  be  brought  into  a  single  purview  as  the  morbid  pictures 
to  which  the  name  is  applied. 

"That  is,  there  is  a  diminution  of  electrical  skin-resistance  at  the  appearance 
of  affects. 


GENERAL  PSYCHOPATHOLOGY  85 

Associations  of  Paranoiacs 

These  associations  in  so  far  as  they  arc  pathological,  are  purely 
katathymic,^'  that  is  to  say,  they  exhibit  characteristic  abnormalities 
only  in  cases  where  emotionally  accentuated  complexes  at  the  basis 
of  the  delusional  system  are  brought  into  play.  Many  things  are  then 
brought  into  incorrect  relationship  to  the  delusional  system.  Thus 
one  finds  an  association-readiness  for  certain  definite  impressions,  de- 
lusions of  reference,  coordination  of  inappropriate  material  with  the 
logic  functions,  a  regardless  omission  of  contradictory  matter,  and  a 
false  valuation  of  material  used.  Wherever  the  delusions  do  not  in- 
terfere, the  thinking  process  appears  normal. 

Other  Disturbances  of  Association 

Besides  these  disturbances  of  associations,  which  are  characteristic 
for  definite  illnesses  or  states,  there  are  many  others  of  which  we  have 
no  knowledge;  they  form  the  subsoil  of  delirious,  soporific,  and  many 
confused  twilight  states  in  fevers,  inner  and  outer  toxemias,  in  different 
brain  diseases,  and  the  like. 

Outside  of  schizophrenia  there  are  also  pathological  brevities  of  the 
associations:  the  patient  always  gets  through  with  his  thoughts  quickly, 
whether  they  are  his  own  or  those  which  have  been  induced  from  the 
outside  by  means  of  questions  and  suggestions.  The  patient  does  not 
think  of  related  ideas  even  when  they  might  have  to  follow  of  neces- 
sity, as  in  the  case  of  wishing  to  give  an  account  of  something  (indeed, 
this  occurs  without  the  existence  of  obstructions  or  melancholic  inhibi- 
tions). Besides  certain  dulled  states  of  schizophrenia,  such  associa- 
tions are  encountered  in  organic  psychoses,  in  rare  epileptic  conditions, 
in  many  light  forms  of  soporific  states,  and  in  similar  conditions. 

A  state  of  monideism  may  be  due  to  many  other  causes  besides  de- 
pressive retardation;  one  observes  this  phenomenon  in  all  forms  of 
twilight  states,  where  only  one  idea  systematically  dominates  the 
patient,  as  for  example,  to  set  fire  to  something,  while  he  has  no  con- 
ceptions of  the  cause  or  consequences  of  the  action.  The  same  state 
is  also  seen  in  deliria  following  mild  cerebral  concussions,  where  any 
confused  idea  accidentally  occurring  to  the  patient  completely  absorbs 
him  for  a  long  time  and  from  which  he  cannot  be  freed  even  by  out- 
ward distraction.  It  is  quite  clear  that  in  these  states,  monideism  is 
something  fundamentally  different  from  what  it  is  in  inhibitions. 

The  disturbances  previously  referred  to  under  brain-pressure, 
toxemias,  and  the  like,  are  not  yet  fully  known. 

"  See  pp.  34-35. 


86  TEXTBOOK  OF  PSYCHIATRY 

"Confusion" 

Confusion  is  not  a  unitary  disturbance  of  association  in  the  same 
sense  as  those  which  have  been  described  thus  far,  but  it  is  the  ex- 
pression of  quite  different  anomalies  of  the  mental  stream  which  have 
attained  a  higher  grade.  It  is  neither  a  unitary  symptom  nor  a  morbid 
picture  and  can  even  be  produced  by  disturbances  outside  of  the  realm 
of  the  usual  concepts  of  associations.^^ 

Of  the  familiar  disturbances  of  association  it  is  naturally  the  schizo- 
phrenics which  most  readily  reach  to  the  point  of  confusion,  because 
it  is  in  their  very  nature  to  tear  thoughts  apart.  In  the  acute  stages 
of  schizophrenia  it  happens  that  not  only  the  thoughts  become  con- 
fused, but  the  false  connection  of  the  primary  associations  to  the  sense 
impressions  already  leads  to  illusional  disorientation.  Nor  do  the 
movements  correspond  to  the  thoughts,  they  may  even  appear  dis- 
turbed in  their  coordination.  In  the  same  way  paramimic  and  para- 
thymic  phenomena  become  connected  with  it. 

Confusions  incident  to  delirious  and  twilight  states  are  still  quite 
insufficiently  known. 

Occasionally  flight  of  ideas  may  become  intensified  to  the  point 
of  confusional  flight  of  ideas;  it  is,  however,  necessary  to  guard  against 
mistaking  it  for  schizophrenic  disturbance  of  associations,  complicated 
by  flight  of  ideas.  As  every  one  knows,  marked  emotional  fluctuations 
in  normal  and  diseased  persons  lead  to  affective  confusion  at  some 
time  or  other. 

The  expressions,  incoherence  and  dissociation,  which  often  designate 
confused  processes  of  thought  apply  most  correctly  to  schizophrenic 
disturbances  of  association,  but  signify  nothing  of  a  characteristic 
nature. 

DiFFUSENESS   AND    CIRCUMSTANTIALITY 

In  the  discussion  of  the  associations  in  epilepsy  we  have  mentioned 
circumstantiality  and  diffusenessP  This  symptom  occurs  also  as  the 
result  of  other  disturbances  and  in  any  case  has  different  origins.  As 
long  as  the  flighty  patient  can  still  come  back  to  his  main  subject,  he 
may  be  considered  circumstantial,  because  he  works  out  many  details 
and  secondary  material  which  are  not  needed.  Thus  diffuseness  is 
often  the  first  striking  indication  of  incipient  mania. — An  imbecile 
can  be  circumstantial  because  he  is  incapable  of  distinguishing  between 
essentials  and  non-essentials  and  hence  he  must  go  into  unimportant 
matters  as  fully  as  into  main  issues.     Repetitions  and  tautologies, 

'"See  below:  "Hallucinatory  Confusion." 

^  Two  not  identical  concepts,  which,  however,  coincide  for  the  most  part. 


GENERAL  PSYCHOPATHOLOGY  87 

characteristic  of  the  circumstantial  epileptic  train  of  tiiougfit,  arc 
usually  absent  in  manics  and  imbeciles.  It  is  well  known  that  senile 
patients  also  become  circumstantial,  partly  because  the  train  of 
thought  gets  into  ruts  which  they  are  no  longer  capable  of  avoid- 
ing, and  partly  particularly,  because  the  substantiality  of  the  affective 
tone  and  the  narrowing  of  the  associations  making  reflection  diffi- 
cult, makes  the  nonessentials  appear  as  important  as  the  main 
theme.  There  are  perhaps  still  other  unknown  reasons  for  the  senile 
circumstantiality. 

Circumstantiality  sometimes  originates  from  a  feeling  of  uncer- 
tainty which  impels  the  patient  to  add  all  sorts  of  corrective  and  sup- 
plementary determinants.  In  this  form  it  may  appear  in  the  most 
varied  states.     It  is  also  utilized  to  put  off  an  unwished  for  decision. 

Overvalued  Ideas,  Obsessions  (Obsessive  Acts) 

Overvalued  Ideas  are  ideas  that  always  obtrude  themselves  into 
the  foreground,  they  are  mostly  remembrances  of  an  affectful  experi- 
ence, but  in  contrast  to  autochthonous  ideas  the  patients  do  not  per- 
ceive them  as  strange,  and  contrasted  with  compulsive  ideas  are  not 
felt  as  incorrect.  They  are  completely  bound  up  with  the  personality 
and  differ  from  ordinary  affective  ideas  only  in  the  fact  that  eventually 
one  does  not  get  rid  of  them  and  that  they  have  the  tendency  to 
associate  themselves  with  new  experiences.  According  to  Wernicke 
they  are  not  delusions  in  themselves,  but  through  morbid  relationships 
often  give  occasion  for  delusions.  They  are  katathymic  ideas,  which 
according  to  the  current  conception  appear  as  the  only  essential  symp- 
tom in  persons  that  would  otherwise  be  considered  sane.  Ziehen,  how- 
ever, also  designates  as  overvalued  ideas,  obsessions,  and  many  obtrud- 
ing delusions.  In  positing  overvalued  ideas  the  question  of  the  exist- 
ence of  monomanias,  which  for  nearly  a  half  century  appeared  settled 
in  the  negative,  has  once  more  been  taken  up,  though  in  a  much  more 
comprehensible  form.  In  the  case  of  an  existing  predisposition  or 
without  this,  is  it  possible  for  an  outer  experience,  intensified  by  an 
accidental  cause,  to  provoke  delusions  in  a  psyche  not  really  morbid? 
I  should  like  to  answer  in  the  affirmative.  But  only  when  these  "over- 
valued ideas"  become  an  active  influence  does  one  deal  with  a  real 
psychosis  (compare  on  the  one  hand  "belief"  and  on  the  other 
paranoia). 2* 

Obsessions  or  compulsive  notions  are  ideas  which  continually 
obtrude  themselves  against  the  patient's  will  with  or  without  exiernal 

"  Some  designate  as  monomanias  not  delusional  forms  in  otherwise  retained 
lucidity,  but  isolated  morbid  impulses  like  kleptomania  or  pyromania. 


88  TEXTBOOK  OF  PSYCHIATRY 

cause,^^  the  content  of  which,  however,  is  recognized  as  incorrect  except 
in  states  of  strong  affects.  Nevertheless  they  do  not  appear  strange  to 
the  personality  as  they  are  regarded  as  the  product  of  one's  own 
thinking.  They  are  remarkably  monotonous  and  may  be  divided  into 
four  groups:  Some  people  feel  compelled  to  put  definite  questions  to 
themselves,  many  of  which  are  foolishly  banal,  such  as,  "Why  has  a 
chair  four  legs?",  some  deal  with  insoluble  problems  about  final  causes, 
such  as,  "What  existed  before  the  creation  of  the  world?",  some  are 
more  or  less  of  a  religious  nature,  such  as,  "Why  is  God  a  man?",  or 
"How  is  the  immaculate  conception  possible?",  and  some  are  of  a  sexual 
content,  which  are  often  also  plainly  an  element  in  those  previously 
mentioned  ("Reasoning  mania") .  Others  have  anxious  ideas  that  the 
match  has  not  been  put  out,  or  the  door  isn't  locked.  They  cannot 
mail  a  letter,  because  in  spite  of  repeated  examinations  they  are  not 
convinced  that  it  is  in  the  right  envelope,  or  that  there  isn't  a  serious 
mistake  in  it.  They  are  afraid  to  touch  a  door  knob  because  they 
themselves  may  carry  germs  to  others,  or  others  to  them  ("delire  du 
toucher").  If  a  knife  is  lying  around,  they  fear  they  may  kill  some- 
body with  it — usually  one  of  their  relatives. 

Others  fear  their  father  may  die  if  a  spoon  lies  on  the  table  in  a 
particular  way,  or  if  one  does  this  or  doesn't  do  that,  in  which  cases 
one  cannot  always  tell  whether  the  patients  are  fully  convinced  of 
the  incorrectness  of  the  "superstition."  Obsessions  that  some  horrible 
crime  was  committed  may  merge  directly  into  delusions  of  sin,  which 
then  also  appear  most  frequently  in  states  of  melancholia.  The  phobias 
are  also  classed  with  obsessions.  Thus  one  observes  an  agoraphobia 
or  fear  of  open  places,  erythrophobia  or  fear  of  blushing,  and  similar 
ideas  which  realize  the  dreaded  occurrence  (fear  of  getting  diarrhoea 
where  it  is  impossible  to  satisfy  this  need) ;  this  can  be  brought  about 
through  the  activity  of  the  smooth  muscular  system  which  is  not 
controlled  by  the  conscious  will.  Other  phobias,  like  mysophobia,  or 
fear  of  dirt  and  eventually  infection,  belong  to  the  group  of  delire  du 
toucher,  and  lead  indirectly  to  actions. 

Some  of  the  compulsive  acts  are  the  result  of  the  compulsive  ideas 
and  cannot  therefore  be  separated  from  them.  Thus  the  idea  that  the 
door  is  not  locked  compels  the  patient  to  try  it  over  and  over  again  or 
ask  others  to  examine  it.  Mysophobia  compels  one  to  touch  the  door 
knob  only  through  cloth  and  to  wash  the  hands  continually.  The 
notion,  "If  I  do  not  return  the  money,  my  father  will  die,"  compels  one 
to  return  it  even  under  difficult  circumstances.    Obscene  contrast  ideas 

"  They  are  in  this  way  also  disturbances  oj  the  will  in  so  far  as  the  patient 
has  no  power  to  direct  his  thoughts  to  normal  thinking. 


GENERAL  PSYCHOPATHOLOGY  89 

compel  one  to  utter  them  (coprolalia).  Often  the  obsession  and  the 
compulsive  impulse  are  identical  as  in  the  impulse  to  kill  one's  child 
with  the  nearby  knife,  or  the  thought  presents  itself,  like  a  halluci- 
nation, in  imperative  form,  "You  must  kill  your  child." 

A  man  who  has  a  questionable  affair  must  turn  around  and  look  at 
every  "dark,  tall,  sturdy"  woman,  then  also  at  small  ones,  then  at  all 
women,  then  also  at  men,  and  then  at  street  cars  to  read  their 
numbers. 

Another  kind  of  association  between  an  obsession  and  compulsive 
impulse  was  shown  by  a  patient,  who  was  not  melancholic;  he  had  the 
obsession  that  he  had  had  intercourse  with  his  mother  and  the  com- 
pulsive impulse  to  write  this  fact  on  banknotes. 

Connected  with  the  compulsion  is  a  very  painful  affect;  still  not  all 
patients  can  rouse  themselves  to  the  state  of  really  desiring  to  be  cured, 
in  spite  of  the  fact  that  a  feeling  of  sickness  is  perhaps  never  lacking 
The  ideas  themselves  are  either  of  a  depressive  -^  content,  or  anxiety 
appears  as  soon  as  the  patient  wants  to  resist  the  impulse.  It  is 
anxiety  that  makes  it  impossible  for  the  patient  to  suppress  the  impulse 
in  spite  of  the  fact  that  he  is  willing  and  knows  better.  But  the 
patient  has  to  see  repeatedly  that  the  match  is  out,  not  so  much  to 
prevent  a  fire,  as  to  rid  himself  of  his  fear,  indeed  the  execution  of  a 
compulsive  act  may  actually  be  connected  with  "a  peculiar  feeling  of 
voluptuous  satisfaction."  The  fear  itself  often  seems  to  be  (incor- 
rectly) the  result  of  the  idea  (fear  of  germs) ;  at  times  it  accompanies 
the  idea  and  more  rarely  it  appears  as  primary,  in  which  case  the  obses- 
sion may  give  the  impression  as  if  it  were  created  as  an  explanation 
for  the  affect.  But  it  is  probably  true  that  obsessions  most  frequently 
develop  on  the  basis  of  a  timid,  uncertain,  but  conscientiously  inclined 
character,  also  in  exhaustions  and  melancholies. 

Freud  has  attempted  to  explain  obsessions  by  assuming  that  any 
relatively  innocent  idea  is  connected  with  another  which  became 
repressed  on  account  of  its  unbearable  content.  The  former  then 
receives  the  affective  endowment  of  the  idea,  which  has  become  un- 
conscious, and  forces  itself  into  consciousness  in  place  of  it.  Thus  a 
girl  at  a  concert  feels  the  impulse  to  micturate  in  the  course  of  sexual 
thoughts  which  she  rejected  as  immoral;  thereupon  at  ever>'  similar 
state  of  affairs  she  had  a  phobia  that  she  might  have  to  micturate. 
It  is  certain  that  obsessive  cleanliness  may  frequently  be  traced  to 
the  need  for  moral  purity,  as  in  onanistic  pangs  of  conscience. 

Obsessions  occur  temporarily  in  neurasthenic  and  melancholic 
states,  in  schizophrenia,  and  also  as  a  special,  and  frequently  ver\' 

**  At  present  I  doubt  whether  there  are  obsessions  of  a  pleasant  content. 


90  TEXTBOOK  OF  PSYCHIATRY 

severe,  disease,  in  people  originally  disposed  to  such  abnormities  (Com- 
pulsion Insanity,  compulsion  neurosis). 

Delusions 

Errors  originate  from  the  facts  that  similar  things  are  considered 
identical  (camelia — rose;  whale — fish),  that  a  simple  coincidence  is 
considered  a  regular  coincidence  and  consequently  taken  as  a  causal 
determinant  (e.g.  the  patient  became  well  because  a  charm  was  ap- 
plied), or  that  something  important  is  overlooked  (the  earth  is  a 
plane)  or  also,  that  one  is  deceived  by  the  senses,  and  hence  unusual 
relations  are  judged  according  to  usual  relations,  e.g.,  the  sun  revolves 
around  the  stationary  world.  Such  errors  may  be  corrected  by  new 
experiences  which  are  enlightening  to  the  extent  that  reason  is  capable 
of  evaluating  these  experiences  correctly.  Even  when  a  person  is  too 
stupid  to  comprehend  the  sphericity  of  the  earth,  we  do  not  call  his 
conception  a  delusion.  Delusions  are  incorrect  ideas  created,  not  by 
an  accidental  insufiiciency  of  logic,  but  out  of  inner  need  ("Delusional 
need,"  Kraepelin) .  There  are  no  other  inner  needs  than  the  affective. 
Delusions,  therefore,  always  follow  a  definite  direction  corresponding 
to  the  patient's  affects,  and  in  the  vast  majority  of  cases  cannot  be 
corrected  by  new  experience  or  instruction,  as  long  as  the  condition 
which  gave  origin  to  them  continues. 

Delusions,  therefore,  have  their  psychological  analogy  not  in  error 
but  in  belief.  Accordingly  the  chief  delusion  is  regularly  egocentric 
and  of  essential  significance  for  the  personality  of  the  patient  himself, 
though,  of  course,  the  forms  of  explanatory  and  secondary  delusions  ^'^ 
need  not  directly  concern  the  patient.  Contrasted  with  belief  the  main 
difference  lies  in  the  fact  that  delusions  are  formed  by  individuals 
from  personal  need  and  that  they  may  relate  to  matters  which  in  sane 
persons  are  subject  to  correction.  We  see  that  the  difference  is  not 
absolute.  Ordinarily  we  cannot  speak  of  delusions  when  a  pious  person 
forms  his  own  opinion  of  religious  matters;  but  when  his  innovations 
appear  altogether  too  gross,  we  designate  them  as  "delusions  of 
religion,"  although  in  the  forum  of  pure  logic  a  new  prophet  might 
have  as  much  reality  value  as  the  older  ones. 

Delusions,  therefore,  originate  as  a  result  of  affects  inasmuch  as 
what  corresponds  to  the  affect  is  accepted  and  what  is  opposed  to  it 
is  inhibited  to  the  extent,  that  it  either  does  not  appear  at  all  in  this 
connection,  or  it  is  of  insufficient  logical  force.  The  melancholic,  when 
he  takes  account  of  his  fortune,  sees  continually  all  his  debts  and 
difiiculties  but  cannot  balance  them  with  his  assets,  partly  because  he 

''See  below. 


GENERAL  PSYCHOPATHOLOGY  91 

considers  them  worthless  or  too  uncertain,  and  partly  because  he 
cannot  connect  them  in  a  logical  procedure  with  the  idea  of  his  debts 
and  therefore  cannot  utilize  them  to  overcome  the  idea  of  indebtedness. 
Such  is  the  origin  of  the  delusion  of  poverty.  Not  infrer4uently  he 
comes  to  the  same  conclusion  by  keeping  back  altogether  the  ideas 
referring  to  exact  sums,  and  only  in  a  general  way  considers  his  debts. 
The  onanistic  schizophrenic  fears  that  his  vice  will  become  known. 
If  he  notices  that  some  one  looks  at  him  he  thinks  it  is  because  of 
his  onanism,  the  self-evident  fact  that  one  is  looked  at  a  thousand 
times  without  such  cause,  cannot  be  used  as  a  counter-argument. 

The  delusional  affect  may  be  of  a  general  (depressive  or  manic) 
nature,  or  it  may  be  attached  only  to  a  particular  idea,  to  a  complex 
such  as  an  onanistic  pang  of  conscience.  In  the  latter  case  katathymic 
delusional  forms  originate.  When  a  person  obsessed  with  a  complex 
is  at  the  same  time  suffering  from  a  general  depression,  a  frequent 
occurrence  in  schizophrenia,  the  katathymic  and  depressive  effects 
become  connected.  If  the  schizophrenic  onanist  is  melancholic  he 
thinks  that  he  is  rotting  because  of  his  vice;  if  he  is  manic,  he  feels 
that  he  is  a  savior  of  humanity. 

Some  of  the  delusions  follow  logically  from  those  already  existing 
and  do  not  require  this  mechanism.  When  the  patient  is  convinced 
that  the  physician  wants  to  murder  him  and  after  taking  medicine  he 
feels  indisposed,  then  it  is  a  conclusion,  based  on  logical  probability, 
that  the  physician  has  prescribed  poison  (secondary  delusion).  Or 
the  patient  is  the  son  of  a  count,  consequently,  his  parents  are  only 
foster  parents.  Or  the  patient  is  pursued  everywhere,  no  matter  where 
he  journeys;  "therefore  there  exists  an  entire  organization  against  him, 
the  postal  authorities  open  his  letters  and  tell  his  address"  (Explana- 
tory Delusions). 

It  is  said  that  delusions  are  logically  deduced  from  the  affective 
disturbance.  Thus  the  patient  feels  unhappy,  seeks  a  cause  and  finds 
it  in  his  sins.     I  have  never  been  able  to  observe  this  mechanism. 

Other  delusions  are  said  to  originate  in  hallucinations,  deceptions 
of  memory,  and  in  dreams.  This  is  undoubtedly  a  question  of  con- 
comitant circumstances,  not  of  real  causes.  It  is  the  false  idea  which 
is  directly  generated  by  the  disease;  it  may  appear  first  as  a  thought, 
or  hallucination,  or  memory  deception,  or  as  a  dream  conception. 

Some  delusions,  especially  in  schizophrenia,  suddenly  appear  in 
consciousness  as  finished  products  [delire  d'emblee,  primordial  de- 
lusion) ;  ^^  others  have  a  longer  period  of  incubation.     For  instance, 

*"!£  the  patient  takes  a  critical  attitude  toward  the  content  of  the  idea,  it  is 
called  an  autochthonous  idea  {Wernicke). 


92  TEXTBOOK  OF  PSYCHIATRY 

the  patients  feel  as  if  they  were  watched,  as  if  they  had  sinned,  until 
at  last  it  becomes  a  certainty.  Or  for  years  the  patients  make  a 
number  of  remarkable  observations  (self-references)  and  it  suddenly 
comes  to  them  "as  a  revelation"  that  it  all  has  this  and  that  meaning. 
Perhaps  most  frequently  the  delusion  connects  itself  with  external 
events  in  such  a  manner  that  the  patients  at  first  quite  correctly  grasp, 
e.g.,  a  sermon,  but  later  on,  following  a  period  of  incubation  of  from 
hours  to  years,  they  interpret  the  words  heard,  consciously  or  uncon- 
sciously, in  the  sense  of  the  delusion  as  related  to  themselves,  that  is, 
to  their  complexes. 

The  following  classes  are  differentiated  according  to  content: 

Expansive  forms  of  delusion;  "Delusions  of  grandeur."  In  the 
mildest  cases  they  rather  take  the  form  of  overestimation  of  the  ego, 
the  patient  surpasses  other  people  in  health,  ability,  beauty  to  an 
extent  greater  than  the  corresponding  reality.  From  this  we  observe 
all  stages  of  real  delusions,  from  the  easily  possible  to  what  is  still 
conceivable  up  to  the  idea  that  the  patient  is  capable  of  the  most 
impossible  discoveries,  to  possess  "trillions,"  to  found  new  religions, 
to  be  God  and  Super-God.  Occasionally  the  environment  is  trans- 
formed to  accord  with  the  idea.  The  patient's  companions  in  the 
asylum  are  mistaken  for  counts  and  potentates. 

Depressive  delusions  refer  especially  to  three  spheres:  to  conscience, 
as  delusions  of  sin;  to  health,  as  delusions  of  disease,  and  to  fortune, 
as  delusions  of  poverty. 

The  patient  entertaining  delusions  of  sin  believes  without  reason  to 
have  committed  the  worst  transgressions  or  magnifies  actual  trivial 
deeds  into  unpardonable  sins.  For  these  not  only  the  patient  is 
punished  in  an  appalling  manner  here  and  in  the  life  beyond,  but 
also  all  his  relatives,  even  the  whole  world. 

The  patient  having  depressive  delusions  of  sin  ^^  believes  that  he 
has  definite,  and  always  especially  awful  diseases.  The  real  disease, 
melancholic  depression,  is  denied.  The  same  is  sometimes  designated 
as  hypochondriacal  delusions;  but  we  must  be  able  to  differentiate 
between  this  delusion  of  general  depression  and  the  katathymic  delu- 
sion that  stands  out  in  the  hypochondriacal  morbid  picture  especially 
in  dementia  praecox,  but  also  in  psychopathic  patients. 

Usually  the  difference  consists  also  in  the  fact  that  the  depressive 
delusion  of  disease  postpones  the  worst  for  the  future,  while  the  kata- 
thymic hypochondriac  worries  about  the  present.  The  depressive 
patient  believes  he  suffers  from  closure  of  the  intestines  and  will  perish 

"  Not  identical  with  the  usually  katathymic  hypochondriacal  delusions  of 
disease. 


GENERAL  PSYCHOPATHOLOGY  93 

in  a  particularly  disgusting  way,  while  the  hypochondriac  asserts  that 
he  actually  suffers  from  intestinal  inactivity  and  demands  and  expects 
relief. 

Impoverishment  is  often  thought  of  in  forms  which  cannot  occur, 
at  any  rate  nowadays;  not  only  is  the  patient  punished  for  his  debts 
and  must  starve,  but  his  relatives  also  meet  with  the  same  fate. 

In  demented  organic  patients  we  see  a  fourth  group  of  depressive 
delusions  which,  though  not  very  common,  furnishes  the  diagnosis  when 
it  is  present,^"  viz.,  nihilism,  which  roughly  corresponds  to  the  delire 
de  negation  emphasized  by  the  French,  or  delusions  of  negation,  which 
are  not  to  be  mistaken  for  the  negativistic  manifestations.  In  this 
case  everything  no  longer  exists,  the  institution,  the  world,  the 
Almighty,  and  the  patients  themselves;  they  have  not  eaten,  yet  they 
have  not  fasted;  they  have  no  name,  are  not  men,  women,  etc.  Also 
in  the  delire  d'enormite,  which  occurs  under  similar  circumstances  and 
is  frequently  connected  with  nihilism,  the  same  nonsense  finds  expres- 
sion: The  patients  may  not  use  a  chamber  because  they  would  flood 
the  entire  institution  or  the  whole  world;  they  are  swollen  up  so  big 
that  they  fill  up  the  entire  house  and  city,  and  choke  everybody ;  they 
must  swallow  everyone  in  the  institution  and  there  are  so  many  of 
them.  In  a  certain  sense  the  opposite  of  this  is  micromania,  which 
also  only  occurs  in  organic  depressions.  It  consists  in  the  fact  that 
the  patients  believe  themselves  to  be  physically  very  small;  thus  a 
senile  scholar  was  afraid  of  chickens  because  he  believed  his  head  was 
so  small  that  it  might  be  pecked  off. 

Depressive  delusion  may  in  rare  cases  be  combined  with  a  kind  of 
megalomania  in  melancholies,  who  are  not  satisfied  to  be  the  worst 
person  that  ever  existed  and  ever  will  exist,  but  attain  the  rank  of 
the  head  of  the  devils.  This  is  also  found  in  schizophrenics  where 
different  kinds  of  affects  appear  together  and  express  these  in  parallel 
delusions,  such  as,  they  are  the  Mother  of  God  and  at  the  same  time 
the  devil,  or  in  a  condensation  such  as,  they  are  Queen  of  the  Night. 

Delusions  of  persecution  do  not  belong  to  the  depressive  forms  of 
delusion.  The  delusion  of  deserved  punishment  must  not  be  classed 
with  that  of  the  unjust  persecution.  The  former  comes  from  a  general 
depression,  the  delusion  of  persecution  is  a  katathymic  symptom,  which 
grows  from  a  single  emotionally  toned  idea.  Every  depressive  delusion 
is  a  symptom  of  a  potentially  transient  condition,  but  the  delusion  of 
persecution  mostly  belongs  to  chronic  diseases.  An  affective,  not  kata- 
thymic delusion  of  persecution  is  the  delusion  of  anxiety  seen  in  hal- 

**  At  the  most  it  can  be  said  that  something  similar  is  seen  in  schizophrenia 
but  it  is  not  identical. 


94  TEXTBOOK  OF  PSYCHIATRY 

lucinatory  conditions  such  as  dreams,  delirium  tremens,  epilepsy,  and 
schizophrenia. 

The  real  delusion  of  persecution  may  at  first  be  quite  indefinite; 
the  patients  feel  that  things  and  people  about  them  have  become 
uncanny  ("the  walls  in  my  own  home  wanted  to  devour  me") .  Then 
they  make  the  discovery  that  certain  persons  make  signs  to  them  or 
to  others  which  refer  to  them.  One  coughs  in  order  to  indicate  that 
here  comes  the  onanist,  or  the  murderer  of  girls.  There  are  articles 
in  the  papers  with  all  too  plain  allusions  to  them;  in  business  they  are 
badly  treated,  the  attempt  is  made  to  get  rid  of  them  through  dis- 
gusting treatment,  the  most  difficult  work  is  assigned  to  them  and 
they  are  slandered  behind  their  backs.  Finally  there  are  entire 
organizations,  created  for  "this  very  purpose,  the  "Black  Jews,"  as  well 
as  the  "Free-Masons,"  "Jesuits"  and  "socialists"  which  everywhere 
pursue  the  patient,  and  make  him  powerless.  They  plague  him  even 
with  voices,  physical  influences,  and  other  hallucinations  as  well  as 
with  withdrawal  of  his  thought,  crowding  of  thought  and  other 
annoyances.  Not  so  seldom  the  delusion  of  persecution  is  combined 
with  grandiose  ideas.  A  certain  overestimation  of  self  generally  lies 
at  the  bottom  of  it,  insofar  as  the  patient  makes  some  kind  of  unattain- 
able demands  and  then  looks  for  the  cause  of  his  failure  in  the  environ- 
ment. It  is  also  said 'that  the  delusion  of  grandeur  originates  in  the 
delusion  of  persecution  through  the  fact  that  the  patient  says  to  himself 
that  a  person  who  is  subjected  to  so  much  persecution  must  be  some 
extraordinary  person.  This  transformation  of  the  delusion  I  have 
never  plainly  observed.  On  the  other  hand,  we  frequently  see  that 
erotic  delusions  turn  into  delusions  of  persecution  or  fuse  with  them, 
in  that  the  imagined  affectionate  lover  commits  sexual  and  finally  other 
atrocities  on  the  beloved. 

An  erotic  form  of  delusions  of  persecution  is  the  delusion  of  jealousy 
which  exhibits  several  peculiarities.  There  are  paranoiacs  who  have 
no  other  delusions ;  in  schizophrenia  it  is  not  seldom  mingled  with  other 
ideas  of  persecution,  and  in  alcoholism  and  cocainism  it  usually  appears 
as  a  temporary  result  of  the  poison  which  is  not  yet  fully  explained. 

The  delusion  of  reference,  or  the  morbid  reference  to  oneself,  has 
been  distinguished  as  a  special  form  of  delusion.  It  occurs  especially 
in  paranoiacs  and  paranoid  forms,  in  which  it  often  forms  the  base  of 
the  other  delusions.  Such  patients  can  relate  to  themselves  absolutely 
indifferent  observations  such  as  coughing,  newspaper  advertisements, 
and  even  cosmic  occurrences ;  they  think  that  everything  occurs  on  their 
account  and  interpret  it  in  the  sense  of  their  katathymic  mental  trend. 
Something  similar  also  occurs  in  general  emotional  depressions.    Melan- 


GENERAL  PSYCHOPATHOLOGY  95 

cholics  especially  like  to  believe  that  any  misfortune  is  the  result  of 
their  badness. 

Thus  one  tells  improbable  things, -to  test  the  patient's  intelligence. 
In  the  newspaper  it  says  that  some  one  fell  downstairs  in  order  to  make 
the  patient  understand  that  she  doesn't  clean  the  stairs  properly 
Some  one  yawns;  that  is  to  say  that  she  is  lazy. 

The  delusion  of  reference  is  explained  by  the  emotional  effects  with- 
out anything  further.^^  Every  affective  idea  has  even  in  normal  per- 
sons many  attachments  that  do  not  correspond  to  reality.  It  is  known 
that  any  one  coming  into  a  ball  room  or  wearing  a  uniform  for  the  first 
time,  believes  himself  noticed,  etc. 

It  has  been  maintained  that  delusions  are  a  sign  of  mental  weakness^ 
since  a  normal  intelligence  would  see  the  incongruity.  But  it  is  certain 
that  there  are  very  capable  paranoiacs  evincing  a  complete  delusional 
system,  who  exhibit  no  other  signs  of  intellectual  disturbance.  If  one 
bases  here  the  assumption  of  mental  weakness  solely  on  the  delusions, 
one  begs  the  question.  The  essential  factor  in  the  formation  of  a 
delusion  is  the  disproportion  between  affect  and  logical  strength  which 
may  have  originated  in  the  preponderance  of  a  general  mood,  as  for 
example  in  melancholia,  or  in  an  especially  strong  affective  coloring  of 
a  single  idea  as,  for  example,  in  katathymic  delusional  formations,  or  in 
the  weakness  of  the  logical  capacity  as,  for  example,  in  paranoid  and 
twilight  state,  or  in  several  of  these  forces  acting  together,  as,  for 
example,  in  manic  paresis. 

This  formulation  naturally  indicates  only  one  comprehensible  con- 
dition of  delusional  formations  out  of  the  others  that  have  not  yet  been 
ascertained.  There  are  many  disproportions  between  intelligence  and 
affectivity  that  do  not  lead  to  delusions,  e.g.,  the  oligophrenias.  The 
type  of  affectivity,  the  transformation  of  the  entire  psyche  in  asso- 
ciating, perceiving,  and  feeling,  as  is  shown  by  the  schizophrenic 
process,  and  in  strongly  exaggerated  form  by  conditions  of  clouded 
consciousness,  are  other  important  foundations  of  delusions. 

A  connection  between  intelligence  and  delusions  exists  in  so  far  that 
in  mentally  clear  patients  the  quality  of  the  delusion  depends  on  the 
grade  of  intelligence.  Intelligent  paranoiacs  ''systematize"  their  delu- 
sions, mixed  with  real  facts  they  bring  them  into  a  system  that  is 
usually  logically  connected,  but  which  Tias  a  flaw  especially  in  the 
assumptions  based  on  false  references  to  themselves,  and  on  memory 
illusions — and  here  and  there  in  its  causal  connection.  The  content  in 
itself  is  usually  conceivable  ta  others,  so  that  paranoiacs  sometimes 
infect  even  intelligent,  healthy  persons. 
'•■*' Gf.  association  readiness,  p.  40,  and  attention,  p.  41. 


96  TEXTBOOK  OF  PSYCHIATRY 

Similarly  formed  ideas  in  schizophrenia  have  a  far  weaker  or  no 
logical  connection  and  in  themselves  readily  merge  into  the  absurd. 
Thus  the  patient  was  present  at  Christ's  crucifixion;  he  has  made  all 
inventions,  even  those  used  before  his  birth,  the  bones  are  taken  from 
his  body,  several  times  he  has  been  killed  and  restored  to  life,  and 
similar  absurdities. 

The  disturbance  of  intelligence  and  unclear  thinking  express  them- 
selves in  senseless  delusions  in  manic  and  depressive  conditions  of 
organic  patients. 

The  grandiose  ideas  of  the  manic  depressive  patient  are  usually 
only  overestimations.  He  is  cleverer  than  all  those  that  lock  him  up, 
he  strikes  down  a  dozen  keepers,  he  will  expand  his  business,  he  will 
yet  become  a  member  of  the  cabinet.  In  manic  forms  of  paresis  the 
delusion  usually  merges  at  once  into  the  absurd;  the  patient  has  large 
armies  at  his  disposal  which  will  destroythe  institution  and  the  country 
in  which  he  is;  he  is  a  general  although  he  has  never  been  in  service; 
he  has  invented  a  bicycle  with  which  you  can  go  around  the  yorld, 
over  seas  and  mountains  in  three  minutes;  he  is  the  super-God;  the 
female  patient  is  the  mother  of  everybody,  every  hour  the  Almighty 
takes  hundreds  of  children  from  her  body,  etc. 

The  melancholic  has  committed  grave  sins,  for  which  tortures  will 
be  inflicted  on  him  as  on  no  one  else,  he  suffers  from  incurable  diseases. 
But  the  depressive  senile  has  his  brain  hanging  down  over  his  head, 
his  intestines  have  been  replaced  by  a  snake,  his  head  is  made  of  wood. 
There  develop  micromania,  nihilistic  ideas,  and  the  delire  d'enormite. 

In  any  case  one  must  be  careful  in  diagnosing  weakness  of  intelli- 
gence from  the  senseless  content  of  the  delusions.  What  has  been  said 
holds  without  any  reservation  only  for  conditions,  in  which  mental 
clearness  is  not  entirely  absent.  In  twilight  states,  in  toxemias,  in 
fevers  absurd  delusions  may  appear  even  in  patients  who  are  not 
demented,  just  as  in  dreams  of  healthy  persons. 

Occasionally  a  delusion  that  originated  in  a  condition  of  disturbed 
mental  capacity  as  in  a  dream  or  epileptic  delirium  and  which  is  there- 
fore senseless,  cannot  later  be  corrected,  although  the  intelligence  does 
not  now  appear  badly  impaired.  Such  a  residual  delusion  may,  there- 
fore, be  senseless  without  there  being  at  the  same  time  a  correspondingly 
severe  disturbance  of  intelligence. 

The  course  of  delusions  is  quite  varied.  The  simple  affective  and 
delirious  delusional  forms  fluctuate  and  naturally  disappear  with  the 
condition  which  gave  origin  to  them.  The  katathymic  delusions  which 
were  not  generated  by  an  exceptional  condition,  are  "fixed  ideas"  in 
paranoia  and  somewhat  less  regularly  in  schizophrenia,  which  are 


GENERAL  PSYCHOPATHOLOGY  97 

changed  little  even  in  decades  and  hardly  ever  disappear.  Even  the 
seemingly  corrected  delusions  in  schizophrenia  should  rather  be  con- 
sidered as  forgotten  or  pushed  aside;  their  persistence  may  be  shown 
too  often,  especially  in  corresponding  affective  reactions.  Besides 
these,  one  observes  everywhere  delusions  of  diverse  origin,  which 
suddenly  appear  and  rapidly  disappear. 

The  relation  of  the  delusions  to  the  ego  is  usually  very  close.  The 
affect  upon  which  it  is  based  or  the  ideas  themselves  usually  compel 
an  excessive,  often  quite  monideistic  preoccupation  with  it.  A  real 
attempt  was  made  to  poison  a  paranoiac  who  was  always  complaining 
in  an  annoying  way  of  poisoning.  The  experience  was  not  connected 
at  all  with  the  delusion  and  left  him  entirely  indifferent.  But  in  schizo- 
phrenics the  affective  disturbance  and  the  splitting  of  the  psyche, 
especially  in  the  later  stages,  bring  it  about,  as  a  rule,  that  the  ideas 
leave  the  patient  more  or  less  indifferent,  or  that  they  become  separated 
from  the  everyday  ego,  which  concerns  itself  with  the  necessities  of 
ordinary  existence,  and  form  a  world  of  their  own. 

4.    DISTURBANCES  OF  MEMORY 

Hyperf unction  of  memory,  or  hypermnesia,  may  probably  only  be 
ascertained  through  the  fact  that  occasionally  recollections  are  much 
more  vivid  and  distinct  than  at  other  times,  that  they  deal  with  details 
that  are  ordinarily  not  noticed,  and  that  they  reach  back  to  periods 
that  are  not  otherwise  remembered.  Thus  in  a  feverish  disease,  in 
deliria  of  senility,  a  memory  series  of  early  youth,  even  of  earliest 
childhood  may  turn  up.  In  a  hypnotic  state  one  can  at  times  recall 
complicated  details  as  distinctly  as  if  one  again  saw  the  things  in  front 
of  him.  In  a  dream,  also,  details,  that  cannot  be  reproduced  at  all  in 
waking  state,  may  turn  up  with  the  clearness  of  a  sense  impression. 
In  rare  cases  of  schizophrenia,  memory  pictures  obtrude  themselves 
in  the  patient  in  a  disagreeable  way,  in  which  case  they  are  usually 
but  slightly  connected. 

Much  more  important  are  the  hypo  functions.  Theoretically,  one 
may  differentiate  those  of  formation,  of  retention,  and  those  of  the 
ekphoria  of  the  engrams.  In  reality,  however,  the  disturbances  rarely 
concern  only  the  one  or  the  other  function,  and  above  all  we  have  by 
no  means  progressed  so  far  as  to  comprehend  really  all  possible  differ- 
ences referring  to  the  partial  function  chiefly  involved.  A  disturbance 
of  attention,  at  the  time  of  impression,  may  harm  the  recollection  in 
about  the  same  way  as  when  occurring  at  the  time  of  reproduction. 

I  can  hardly  conceive  of  a  qualitative  disturbance  of  the  engraphic 


98  TEXTBOOK  OF  PSYCHIATRY 

effect,  and  in  the  entire  pathology  I  have  found  nothing  that  would 
indicate  its  existence.  On  the  other  hand,  in  senile  atrophy  of  the 
brain  the  engraphic  effect  of  the  experiences  on  the  psyche  is  possibly 
weakened,  and  as  a  result,  the  extensive  effect  must  probably  be 
reduced  also,  for  the  diffuse  extension  of  the  influence  in  the  brain, 
which  is  to  be  assumed  for  numerous  reasons,  diminishes,  and  fewer 
associational  connections  are  formed.  One  can  also  conceive  that  the 
hypothetical  elaboration  of  the  engrams  is  reduced  in  some  way,  but 
is  not  yet  subject  to  any  disturbance  that  would  indicate  the  fact. 
From  the  process  of  remembering  (ekphoria)  we  know  that  it  certainly 
participates  in  many  anomalies  of  memory,  indeed  there  is  nothing 
that  stands  in  the  way  of  assuming  that  disturbances  of  it  alone  can 
explain  most  memory  defects.  Recollection  generally  is  disturbed, 
when  an  affect  causes  a  diffuse  blocking  of  thoughts  as  in  the  case  of 
examination  stupor.  Individually  it  is  difficult  to  remember  that  which 
is  incompatible  with  an  affect  connected  with  self-love  which  strives 
to  manifest  itself.  Transformations  of  a  memory  occur  whenever  there 
is  an  affective  necessity,  which  also  determines  the  direction  of  the 
falsification.^^ 

To  judge  the  unfortunate  concepts  "impressibility"  (Merkfahig- 
keit)  is  not  very  easy  in  pathology.  What  is  considered  under  this 
term  is  in  reality  a  very  complicated  function  which  may  be  disturbed, 
without  changing  the  engraphy  or  the  memory  functions  in  general. 
This  happens  when  for  any  reason  what  should  be  noticed  is  not 
properly  perceived  or  else  not  further  elaborated,  as  in  diseases  of  the 
sense  organs,  in  all  forms  of  disturbances  of  attention,  and  in  reference 
to  more  complicated  matters  in  various  forms  of  dementia  where  things 
perceived  are  not  comprehended.  In  the  latter  case  there  is  no  lack 
of  actual  engrams  of  the  sense  perceptions,  but  there  are  no  associative 
connections  to  assist  in  bringing  them  to  memory.  As  the  most  striking 
hypofunction  of  impressibility  is  that  which  is  described  in  the  organic 
psychoses.  Thus  in  extreme  cases  every  experience,  even  the  most 
important,  is  at  once  forgotten;  a  senile  woman  may  be  told  her  hus- 
band has  died  and  she  will  react  with  tears,  but  a  moment  later  she 
knows  nothing  about  it,  and  this  experiment  may  be  repeated  as  often 
as  desired.  To  be  sure,  in  the  defective  brain  the  formation  of  the 
engrams  may  be  somehow  impeded,  but  this  is  certainly  not  the  essen- 
tial factor,  because  the  organic  disturbances  of  memory  do  not  confine 
themselves  only  to  the  period  of  the  disease  and  are  in  no  way  pro- 
portional to  the  condition  at  the  time  of  impression,  but  much  rather 
to  the  state  existing  at  the  time  of  the  recollection.    Furthermore,  in  not 

^  For  organic  disturbances  of  ekphoria  see  below. 


GENERAL  PSYCHOPATHOLOGY  99 

very  extreme  cases  most  things  are  "noticed,"  notwithstanding,  but  only 
for  a  short  time  are  they  capable  of  ekphorization.  One  also  observes 
in  every  patient  memory  islands,  so  to  say,  as  shown  in  the  fact  that 
some  experience  is  never  forgotten  or  that  a  recollection,  that  did  not 
seem  to  be  there,  suddenly  turns  up  in  a  certain  connection.  Besides, 
the  "economy"  in  time,  which  is  observed  in  releaming  of  material 
apparently  completely  forgotten,  proves  the  persistence  of  a  mnemonic 
after-effect,  even  in  severe  cases  of  Korsakoff's  disease. 

Hence,  in  organic  hypomnesias  one  deals  with  a  disturbance  of 
memory  that  involves  the  more  recent  experiences  disproportionately 
stronger  than  those  lying  further  back,  even  though  what  is  experienced 
during  the  disease  is  for  various  reasons  often  particularly  poorly 
remembered.  Only  this  formulation  covers  all  the  facts.  The  main 
disturbance  is  probably  in  the  ability  to  recall,  although  the  organic 
reduction  of  the  associations  hinders,  on  the  one  hand,  the  formation 
of  paths,  along  which  the  recollections  can  be  afterwards  ekphorized, 
and,  on  the  other  hand,  impedes  the  use  of  these  paths  in  the  process 
of  ekphoria.  In  the  same  way  a  senile  disturbance  of  attention  not 
only  impedes  the  formation  of  engrams  capable  of  recollection  but 
also  their  revival. 

Disturbances  of  the  retention  of  the  engrams  are  not  significant  in 
psychiatry.  In  view  of  the  large  number  of  chance  tests  which  demon- 
strate to  us  not  only  the  unlimited  continuation  of  the  engrams  but 
their  positive  consolidation  through  age,  I  cannot  believe  that  there  is 
such  a  thing  as  a  normal  weakening,  in  the  sense,  that  all  memory 
pictures  become  "weaker"  with  time  and  finally  disappear  entirely,  thus 
producing  a  pathological  exaggeration  of  such  a  process.  Nevertheless, 
organic  disturbances  of  memory  are  considered  from  this  viewpoint 
and  justly  so  inasmuch  as  the  general  reduction  of  their  carriers  must 
naturally  impair  the  engrams  in  some  way ;  but  the  connection  of  these 
changes  with  the  clinical  manifestations  is  certainly  very  complicated. 
It  is  chiefly  the  ekphoria  that  proves  disturbed,  not  the  preservation 
of  the  engrams.  The  disturbance  of  acute  and  chronic  alcoholism 
could  also  be  connected  with  the  change  of  the  engrams.  where  the 
recollections  are  rather  readily  brought  up  but  are  inexact  or  wrong, 
while  the  patient  believes  he  is  reproducing  well.  But  here,  too,  other 
explanations  are  more  probable. 

In  coarse  brain  lesions  it  seems  that  definite  groups  of  memory 
pictures  may  become  affected,  such  as  certain  speech,  or  motor,  or 
acoustic,  or  optical  memory  pictures.  But  the  extraordinarily  indefinite 
and  fluctuating  border  of  such  defects  makes  it  probable,  that  even 
psychic  structures  apparently  so  elementarj',  are  never  totally  de- 


100  TEXTBOOK  OF  PSYCHIATRY 

Btroyed;  that  they  are  therefore  localized  in  the  entire  cortex,  even 
though  their  most  important  part,  their  focus,  is  concentrated  in  a 
definite  region  of  the  brain.  If  the  focus  is  destroyed  then  the  engrams 
can  only  be  ekphorized  exceptionally  and  imi)erfectly,  while  destruction 
of  other  parts  of  the  cortex  affects  them  little  or  in  a  manner  hardly 
noticeable. 

Besides  the  organic  memory  disturbances  there  are  also  various 
diffuse,  unsystematized  forms  of  memory  weakness.  They  show 
nothing  that  is  uniform  and  at  the  present  have  no  great  significance  in 
psychopathology ;  the  main  thing  is  not  to  confuse  them  with  other 
disturbances.  In  the  anamneses  of  schizophrenics  we  very  frequently 
find  the  remark  that  they  have  become  "forgetful,"  that  they  no  longer 
"had  any  memory."  If  such  testimony  of  relatives  were  taken  literally, 
one  would  have  to  conclude  that  one  dealt  with  an  organic  mental  dis- 
turbance because  a  real  weakness  of  memory  does  not  occur  in  schizo- 
phrenia. On  the  other  hand,  schizophrenics  readily  become  indifferent, 
inattentive,  distracted,  and  inhibited  in  their  associations,  all  of  which 
can  bring  it  about  that  they  do  not  recall  things  at  the  desired  time. 
Neurotics,  too,  have  a  very  freakish  memory  for  similar  reasons. 
Onanists  often  complain  of  a  bad  memory,  partly  as  a  result  of  sug- 
gestion through  certain  books,  and  partly  perhaps  as  a  result  of  lack 
of  concentration,  which  is  determined  by  the  distraction  caused  through 
the  complex.  In  epileptics  the  memory  as  a  rule  becomes  weakened 
when  they  already  have  a  marked  atrophy  of  the  brain,  naturally  also 
in  the  organic  sense;  but  this  peculiarity  is  usually  concealed  by  a 
general  weakness  of  memory  which  manifests  itself  now  here  and  now 
there  but  in  which  emotionally  colored  events  can  be  retained  more 
readily  and  reproduced  in  a  stereotyped  way. 

Circumscribed  memory  gaps  are  designated  as  amnesias;  the  cir- 
cumscription may  be  confined  to  content  (systematized)  or  to  time. 
The  former  occurs  in  gross  brain  lesions  in  such  a  way  that  all  optical 
or  all  acoustic  memory  pictures  disappear,  or  only  those  of  substantives 
or  those  of  numerals,  etc.  Naturally,  here,  too,  it  is  not  known  what 
part  of  it  is  due  to  the  memory  pictures  and  what  is  merely  a  difl5culty 
in  ekphorization;  at  all  events,  the  latter  plays  a  big  part  as  may  be 
seen  from  the  reconstruction  of  such  amnesias. 

In  psychoses  one  meets  with  amnesias  for  definite  events  (kata- 
thymic  amnesias) .  During  the  experience  the  patient  was  in  an  ordi- 
nary condition  of  consciousness  and  reproduced  in  a  normal  way  all 
other  events  that  occurred  about  that  time.  Thus  an  hysteric  suddenly 
forgot  everything  that  related  to  her  physician  Janet,  and  mistook  hfra 
for  a  new  assistant  physician.     In  schizophrenia  acts  of  the  individual 


GENERAL  PSYCHOPATHOLOGY  101 

and  of  others  are  "forgotten"  every  day,  when  the  memory  of  the  same 
does  not  just  suit  the  patient.  A  mild  schizophrenic  of  Wernicke  swore 
in  all  good  faith,  nevertheless  falsely,  that  he  had  not  insulted  a  police- 
man (katathymic  amnesia).  In  such  cases  one  can  usually  easily 
demonstrate  in  a  round-about  way — in  hysterics  most  readily  by  hyp- 
nosis— that  the  engrams  concerned  have  not  been  destroyed,  since  the 
recollection  may  again  appear  in  another  connection. 

In  some  cases  the  necessity  exists  to  omit  an  entire  period  of  time, 
as  in  the  case  of  the  hysterical  woman  who  wished  to  forget  her  husband 
and  who  then  recalled  things  only  up  to  the  time  of  her  acquaintance 
with  her  husband.  Thus  originates  apparently  a  temporal  circum- 
scription of  the  amnesia  but  in  which,  nevertheless,  the  content  is  the 
essential  factor  and  which  furthermore  differs  from  the  ordinary 
temporal  amnesias  in  the  fact  that  it  relates  to  a  period  of  normal 
experience. 

The  rarer  negative  hallucinations  of  memory  are  a  little  different. 
Thu«  a  patient,  like  all  the  others,  has  received  his  cigars  for  Christmas ; 
he  smoked  them  up  quickly  and  then  began  to  scold  because  cigars 
were  given  to  all  patients  except  to  him.  The  distinction  between  this 
and  katathymic  amnesia  lies  in  the  hallucinatory  obtrusiveness  of  such 
manifestations.  Wernicke's  patient  did  not  remember  something  that 
he  experienced,  while  upon  the  other  the  recollection  forces  itself  that 
something  that  should  have  happened  did  not  happen.  The  latter  feel 
the  gap  in  what  should  have  happened,  while  the  others  are  not 
conscious  of  any  gap. 

The  most  frequent  kind  of  amnesia  is  the  one  that  follows  disturb- 
ances of  consciousness  of  all  kinds,  especially  twilight  states  and  deliria. 
A  patient  wakes  up  suddenly  after  some  sort  of  behavior  otherwise  not 
in  keeping  with  his  character,  he  does  not  know  at  all  where  he  is, 
how  he  got  there  and  what  has  happened.  He  recalls  things,  up  to  a 
certain  moment,  and  then  recollection  ceases,  somewhat  as  in  a  normal 
person  after  a  "dreamless"  sleep.  As  a  rule  every  point  of  contact  for 
estimating  the  transpired  time  is  lacking;  if  the  twilight  state  has  lasted 
several  days,  the  patient  usually  does  not  feel  the  lack  of  temporal 
orientation  at  all,  or  perceives  it  insufficiently.  As  a  rule  he  under- 
estimates the  duration  of  the  condition,  and  thinks  it  is  the  day  fol- 
lowing the  one  last  remembered,  as  after  an  ordinary"  night's  rest. 

Amnesias  are  also  not  uncommon  after  purely  affective  explosions  in 
psychopathic  or  in  really  insane  patients.  This  is  seen  in  outbursts  of 
prisoners,  in  depressive  and  schizophrenic  excitements,  and  similar 
states. 

The  amnesia  is  not  necessarily  complete.    There  are  all  transitions 


102  TEXTBOOK  OF  PSYTCHIATRY 

from  absolutely  no  memory  up  to  complete  recollection,  just  as  in  the 
recall  of  our  dreams.  This  amnesia  also  resembles  that  following  the 
dream,  insofar  as  it  may  be  variable.  Frequently,  immediately  after 
waking  some  things  can  be  remembered  that  are  forgotten  some  time 
later,  and,  just  the  reverse,  an  initial  total  absence  of  memory  may 
clear  up  in  the  course  of  the  next  hours  or  weeks,  especially  when  the 
patient  is  reminded  of  his  acts.  As  in  every  case  where  there  is  a 
certain  weakness  of  memory,  a  selection  of  the  retained  memories  may 
take  place  even  in  quite  harmless  cases,  which  is  an  exaggeration  of 
normal  states,  inasmuch  as  only  what  is  unpleasant  to  the  patient  is 
altogether  or  mostly  forgotten.  The  knowledge  of  these  incomplete 
amnesias  is  very  important  because  criminal  acts  are  not  seldom  com- 
mitted in  twilight  states  and  in  case  the  patient  shows  a  wavering 
recollection,  the  judge  is  inclined  to  take  simulation  for  granted. 

Also  the  exact  time  of  the  beginning  and  ending  of  the  amnesia 
cannot  always  be  definitely  fixed,  which  may  lead  to  new  difficulties. 
In  part,  but  not  at  all  invariably,  such  a  manifestation  is  connected 
with  the  course  of  the  twilight  state,  in  which  clearer  moments  may 
change  off  with  those  entirely  unclear. 

The  amnesia  may  also  extend  beyond  the  time  of  the  abnormal 
state,  taking  by  preference  a  backward  direction;  this  is  designated  as 
retrograde  amnesia.  This  is  very  often  the  case  after  dreamlike  or 
unconscious  states  in  consequence  of  head  traumas  or  after  attempts 
at  hanging.  The  patients  no  longer  know  at  all  that  they  got  into  the 
situation  that  produced  the  trauma  arid  how  they  got  there.  Antero- 
grade amnesia  ^^  occurs  much  more  seldom  and  perhaps  only  during  a 
gradual  transition  to  lucidity  which  deceives  the  observer  as  to  the 
severity  of  the  condition.  Here  there  is  a  prolonging  of  the  amnesia 
to  the  time  immediately  following  the  attack,  which  period  may  last 
for  hours  or  days. 

During  the  twilight  state  one  usually  can  easily  ascertain  that  the 
patient  can  recall  events  experienced  in  the  same  attack.  One  of  our 
epileptics,  whose  twilight  states  often  lasted  several  weeks,  pretty  regu- 
larly recalled  during  these  attacks  the  occurrences  of  the  last  two  days; 
but  from  this  period  the  amnesia  followed  continually  the  course  of 
time.    Moreover,  the  memories  may  turn  up  again  in  the  next  analogous 

^Unfortunately  this  term  is  also  used  for  various  other  disturbances  of 
memory,  as  for  a  condition  in  which  every  experience  is  at  once  forgotten,  as 
in  our  organic  memory  disturbance,  without  a  consideration  as  to  whether  the 
disturbance  of  recollection  also  extends  to  former  experiences.  It  is  also  used 
in  cases  like  those  of  the  epileptic,  in  the  following  paragraph,  with  whom  the 
anterior  border  of  the  amnesia  followed  the  present  time  by  an  interval  of 
two  days. 


GENERAL  PSYCHOPATHOLOGY  103 

state;  this  is  seen  not  only  in  hypnotic  and  hysterical  twilight  states, 
but  also  in  epileptic  and  even  toxic  states.  A  drunkard,  who  in  a 
drunken  condition  has  mislaid  his  keys,  knows  the  next  time  he  is 
drunk  where  they  are,  etc.  Also  in  the  hypnotic  as  well  as  in  epileptic 
states  many  such  twilight  states  may  be  brought  to  light  again. 

In  the  conditions  that  lead  to  amnesias  we  regularly  have  a 
markedly  changed  mental  activity.  In  the  hysterical  states  and  in 
attacks  of  rage  and  anxiety  it  is  the  emotional  effect  that  produces  a 
different  relation,  in  alcoholic  intoxication  and  in  epileptics  it  is  the 
poisoning  of  the  brain,  while  in  organic  cases  it  is,  doubtless,  chiefly  a 
metabolic  disturbance  in  consequence  of  circulatory  changes,  particu- 
larly through  vascular  occlusions  and  cerebral  pressure.  Under  such 
circumstances  apperception  is  already  inadequate  and  still  more  the 
elaboration  of  things  perceived,  that  is,  there  is  an  inadequacy  in  the 
connection  of  normal  associations  with  the  individual's  existing  sum 
of  ideas  with  the  help  of  which  memories  are  ordinarily  aroused.  All 
of  these  are  additional  impediments  to  the  capacity  to  recall.  Even 
a  normal  person  could  not  recall  the  disorderly  confusion  that  many 
states  of  dimmed  consciousness  present. 

But  the  most  important  factor,  which  is  nearly  always  present,  is 
probably  the  entirely  different  state,  namely,  the  combination  of  ideas 
changed  as  to  content  and  form.  Even  the  health}^  person  does  not 
possess  full  control  over  his  memory  resources  if  he  wants  to  make 
use  of  them  under  unusual  circumstances  or  when  he  is  preoccupied. 
It  cannot  therefore  cause  surprise  if  similar  phenomena  occur  wherever 
there  was  a  change  in  the  usual  state  of  the  association.  If  one  no 
longer  remembers  the  events  of  a  particular  place,  they  often  come 
plainly  into  consciousness  as  soon  as  the  place  is  revisited;  after  a 
manic  depressive  attack  recollections  are  often  dimmed,  but  in  the  next 
attack,  even  if  decades  have  since  passed,  they  may  readily  obtrude 
themselves  with  most  unusual  clearness.  We  have  good  reason  to 
suppose  that  the  amnesia  for  the  first  period  of  childhood  may  be 
attributed  to  the  powerful  transformation  that  the  personality  has  to 
undergo  in  this  period.  That  the  suckling  has  no  memory-  is  naturally 
a  senseless  assumption. 

The  essential  factor  in  many  hysterical  amnesias  is  the  e.vclusion 
of  an  unpleasant  recollection  {or  actual  fact)  from  consciousness. 
This  necessity  has  usually  already  provoked  the  twulight  state.  To 
illustrate : 

Through  clumsy  manipulation  behind  her  husband's  back,  a  woman 
has  made  inroads  upon  his  fortune,  on  account  of  w^hich  her  husband 
wanted  to  leave  her.     She  now  merged  into  a  twilight  state  from  which 


104  TEXTBOOK  OF  PSYCHIATRY 

she  had  excluded  a  large  part  of  time  of  her  married  existence  and 
especially  the  birth  of  a  child  which  occurred  when  her  troubles  began 
and  made  the  situation  more  difficult;  she  could  not  be  brought  to 
herself  through  explanations.  After  a  while  she  became  more  lucid, 
but  only  after  her  husband  had  become  reconciled  to  her  was  she  able 
to  recall  her  guilt  and  the  marital  difficulties;  but  she  could  not  recall 
the  twilight  state. 

The  inability  to  recall  frequently  does  not  lie  in  the  condition  at 
the  time  of  the  experience,  but  in  an  actual  resistance  to  the  ideas 
about  to  be  reproduced.  Even  in  the  case  of  experiences  occurring  in 
clouded  states  only  those  that  are  unpleasantly  accentuated  are  some- 
times conspicuous. 

Thus  an  epileptic  teacher  who  had  stolen  during  a  twilight  state, 
afterwards  knew  nothing  either  of  the  thefts  or  of  the  epileptic  attacks, 
which  he  had  while  under  observation  in  an  institution,  although  he 
had  not  only  been  led  over  both  episodes  but  was  also  convinced  of 
them;  at  the  same  time  he  remembered  well  most  of  the  details  of_his 
flight  to  a  foreign  country. 

As  disturbances  of  ekphoria  we  have  still  to  mention  the  schizo- 
phrenic states  in  which  obstructions,  abnormal  mental  trends,  and  in- 
coherence prevent  the  finding  of  the  usual  paths.  In  this  connection 
it  should  also  be  mentioned  that  where  few  associations  are  present, 
as  in  organic  cases  and  in  imbeciles,  recollection  may  start  from  fewer 
points,  and,  therefore,  under  certain  circumstances,  proceeds  less  readily. 

Recognition  has  naturally  become  impossible  where  recollection  in 
general  has  ceased.  Senile  patients  often  do  not  recognize  their  nearest 
relatives.  But  recognition  is  retained  much  longer  than  simple  recol- 
lection, for  the  association  of  a  new  impression  with  a  memory  picture 
of  the  same  thing  is  certainly  one  of  the  strongest  impressions,  and 
very  easy  to  find.  Thus  we  also  see  in  examining  the  impressibility 
that,  although  the  patient  is  unable  to  repeat  a  name  just  previously 
mentioned,  he  can,  without  difficulty,  select  it  from  a  number  of  words 
presented  to  him. 

The  alteration  of  the  feeling  tone  and  other  regularly  occurring 
subjective  additions  of  a  perception  which  have  not  yet  been  described, 
can  under  conditions  so  change  the  latter,  that  the  object  appears 
strange  to  us  and  in  rare  cases  is  not  recognized.  Neuropaths  and 
melancholies  very  often  feel  that  everything  seems  strange  to  them, 
but  only  seldom  do  they  consider  the  things  really  changed,  in  schizo- 
phrenics, however,  the  reverse  is  often  the  case. 

As  parafunctions  of  memory  (memory  deceptions)  we  recognize, 
in  the  first  place,  the  inaccurate  recollections.     They  are  found,  as 


GENERAL  PSYCHOPATHOLOGY  lOo 

mentioned  above,  in  acute  and  in  chronic  alcoholism,  but  especially 
in  organic  cases  and  also  in  epileptics.  In  the  latter  similar  memories 
can  easily  be  mistaken  for  each  other  when  such  a  patient,  for  example, 
was  twice  in  prison,  the  two  events  merge  together,  especially  when  he 
is  in  a  twilight  state.  He  then  relates  about  a  time  spent  in  prison 
which  belongs  to  the  other  episode,  and  what  is  even  more  character- 
istic of  epilepsy  is  the  fact  that  he  cannot  get  away  from  the  idea  of 
the  repetition,  and  under  conditions  he  will  continue  to  relate  how 
he  was  discharged  from  prison,  then  worked,  then  came  into  prison, 
and  then  he  was  again  discharged  and  again  locked  up,  etc.  Indistinct 
and  inaccurate  memories  are  also  common  among  those  imbeciles  who 
in  their  concept  formations  do  not  firmly  adhere  to  sensory  perceptions, 
whereas  in  the  others  we  can  often  find  a  remarkably  faithful  repro- 
duction of  experiences. 

On  the  whole,  these  inaccuracies  of  memory  receive  little  attention 
in  pathology.  More  important  are  the  systematic  memory  falsifica- 
tions which  are  designated  as  illusions  and  hallucinations  of  memory. 

The  illusions  of  memory  (paramnesias)  are  exaggerations  to  the 
point  of  pathology,  of  memory  disturbances  which  are  so  frecjuently 
provoked  through  affects  in  healthy  persons.  They  play  a  great  part 
in  all  forms  of  insanity,  but  the  greatest  part  is  played  in  paranoia 
and  schizophrenia.  There  is  no  paranoiac  who  does  not  change  his 
memories  in  the  sense  of  his  delusions,  but  just  here  one  can  some- 
times verify  how  the  original  memory  pictures  as  such  have  not 
been  changed;  the  patient  affirms,  for  example,  "that  the  pastor  had 
preached  about  me.  He  said  that  I  am  now  looked  upon  as  an 
insane  person  and  I  am  not  good  for  anything  else."  On  intensive 
questioning  one  at  first  receives,  despite  all  urging,  the  verbal  quo- 
tations of  the  pastor's  speech  in  the  form  mentioned.  But  if  the 
doctor  and  the  patient  do  not  lose  patience,  one  can  finally  show  that 
the  pastor  said:  "Happy  are  those  who  are  poor  in  spirit,"  but  that  the 
patient  referred  to  herself  the  words  in  the  given  sense  and  translated 
this  sense  in  words  which  she  put  in  the  pastor's  mouth  without  realiz- 
ing it.  In  the  delusion  of  princely  lineage  a  visit  paid  to  the  parents, 
which  in  itself  is  perhaps  insignificant,  is  translated  by  the  patient  as 
a  visit  from  a  minister.  Here,  too,  one  can  often  elicit  through  patient 
questioning  of  the  patient  that  one  does  not  deal  with  anything 
important.  In  both  these  cases,  however,  the  patients  are  not  any  more 
convinced  by  these  analyses,  and  immediately  thereafter  repeat  their 
assertions  in  the  original  form. 

Melancholies  entertaining  delusions   of  sin   are  in  the  habit   of 
investigating  their  whole  life  for  faults  that  they  may  have  committed. 


106  TEXTBOOK  OF  PSYCHIATRY 

They  not  only  make  a  deadly  sin  out  of  such  trivialities  as  stealing 
apples  in  childhood  but  they  also  often  change  the  content  of  the 
memory  in  the  same  sense.  In  their  excitement  manic  patients  easily 
get  into  friction  with  their  environment.  They  are  regularly  the 
aggressors  and  put  the  others  on  the  defense.  Even  during  the  course 
of  the  illness,  but  more  remarkably  also,  even  after  the  attack,  they 
recount  these  experiences  for  the  most  part  in  an  entirely  different 
light,  they  represent  themselves  as  the  ones  who  were  maltreated,  mis- 
understood and  unjustly  attacked.  As  they  are  now  quite  calm  and, 
as  a  rule,  quite  sensible,  it  is  difficult  not  to  believe  them  if  one  is  not 
himself  well  acquainted  with  the  situation.  At  all  events  we  know 
that  patients  suffering  also  from  other  mental  disturbance,  above  all, 
the  clearer  minded  and  litigious  schizophrenics,  behave  in  the  same 
manner  in  similar  situations. 

A  systematic  memory  disturbance  which  is  also  determined  by  the 
affect  is  at  the  basis  of  the  alternating  personality.^^ 

Memory  illusions  which  connect  the  experiences  of  others  with 
one's  own  person  (as  in  the  case  of  appersonation),  merit  special  con- 
sideration. Schizophrenics  sometimes  aver  that  they  experienced 
things  which  really  happened,  but  not  to  them,  but  to  their  nearby 
patients.  Whoever  considers  himself  Christ,  believes  that  he  had  been 
crucified,  and,  under  certain  conditions,  can  delude  himself  into  remem- 
bering the  details  of  it  with  perceptible  acuteness;  to  be  sure,  the 
greatest  part  of  such  products  become  unclear  in  consequence  of  the 
imperfection  of  the  sensible  components  and  are  thus  recognized  as 
incorrect. 

Parallel  with  the  memory  illusions,  we  may  put  those  memory 
deceptions  which  freely  create  a  memory  picture,  which  has  no  con- 
nection with  a  real  experience,  that  is,  the  memory  hallucinations 
which  endow  a  phantasy  with  reality.  The  latter  must  be  taken  in 
the  strict  sense  as  confabulations,  for  they  really  also  deserve  this 
name.  Objectively  they  represent  ideas  having  a  timbre  of  something 
experienced  or  of  something  remembered. 

Memory  hallucinations  appear  almost  exclusively  in  schizophrenics. 
All  of  a  sudden  memories  appear  which  have  no  basis  in  experience. 
The  patient  immediately  begins  to  be  abusive  saying  that  last  night 
he  was  taken  into  the  tower  and  made  to  go  through  all  sorts  of 
gymnastic  tricks,  in  order  to  throw  him  finally  into  the  river.  The 
following  days  the  story  is  continued  and  constantly  becomes  more 
complicated  but  is  seemingly  arranged  after  a  definite  plan.  He  is 
finally  made  to  fly  (before  aviation  came  into  existence)  and  goes 
"  Cf.  below  under  Disturbance  of  Personality. 


GENERAL  PSYCHOPATHOLOGY  107 

through  the  whole  world.  At  the  same  time  it  is  surely  not  a  cjucHtion 
of  verified  dreams  or  of  hallucinations  of  the  senses,  for  many  of  these 
experiences  are  put  back  to  a  period  when  the  patient  was  C4uitc 
normally  occupied  with  work  or  singing.  In  other  cases  the  memory 
hallucinations  are  less  systematized  and  consist  only  of  fragmentary 
details.  The  normal  person  can  easily  read  himself  into  this  ab- 
normity, if  he  thoroughly  observes  his  dreams.  A  great  part  of  the 
experiences  which  are  later  put  into  the  actual  dream,  are  in  reality 
memory  hallucinations  and  immediately  come  up  in  the  associations  as 
memory  and  not  as  a  present  experience. 

Also  in  organic  cases  such  real  memory  hallucination  can  oc- 
casionally appear.  Thus  a  senile  patient  frequently  related  to  us,  how 
he  was  attacked  in  his  room  last  night  by  robbers,  who  tied  one  of 
his  arms  on  his  back,  and  used  his  other  arm  with  the  hand  as  a  scoop 
to  get  out  the  gold  and  silver  from  his  own  money  chest.  Sometimes 
it  could  be  demonstrated  that  he  neither  slept  nor  hallucinated  during 
the  night  in  which  he  located  his  adventure.  As  a  matter  of  fact  no 
hallucinations  of  the  senses  have  ever  been  confirmed  in  him. 

In  confabulations  it  is  also  a  question  of  free  inventions  which  are 
taken  as  experiences.  They  fill  a  memory  gap,  frequently  turn  out 
to  have  been  produced  for  just  this  purpose,  and  change  from  moment 
to  moment.  Indeed  they  can  be  provoked  and  guided  while  memory 
hallucinations  can  no  more  be  changed  than  a  delusion.  One  asks 
an  alcoholic  Korsakoff  patient  where  he  had  been  yesterday,  and 
without  any  reflection  he  recounts  with  great  accuracy  that  he  took  a 
walk  to  the  nearby  mountain.  If  he  is  then  asked  whether  he  Has 
not  seen  the  doctor,  one  can  expect  with  considerable  certainty  that  in 
pronounced  cases,  the  patient  will  answer  in  the  afiirmative  and  will 
describe  where  he  had  seen  him  and  about  what  they  talked  together. 
Now  and  then  such  an  invention  adheres  to  memory,  and  what  is 
remarkable,  also  when  real  experiences  are  forgotten  from  minute  to 
minute. 

Unfortunately  the  term  confabulation  is  also  used  for  vivid  memory 
hallucinations  and  for  half  conscious  phantasy  manifestations  of 
schizophrenia.  We  must,  however,  adhere  to  the  concept  in  the  above 
given  sense  of  the  confabulation,  for  thus  conceived  it  is  a  sign  of 
organic  psychoses  when  observed  in  non-delirious  states.  It  would 
be  good  if  the  name  should  not  be  applied  to  other  anomalies. 

The  most  vivid  confabulations  are  seen  in  many  alcoholic  Korsakoff 
cases;  almost  their  whole  psychic  activity  often  consists  only  of  con- 
fabulations. Many  paretics,  especially  the  manic  types,  spontaneously 
confabulate   in   a   very    profuse   manner.     Confabulations   play   the 


108  TEXTBOOK  OF  PSYCHIATRY 

smallest  part  in  senile  forms,  still,  even  here  it  is  in  many  cases  quite 
easy  to  evoke  the  symptom  if  the  patient  is  asked,  for  example,  what 
he  did  yesterday   (embarrassment  confabulations). 

Related  to  confabulations  are  phantasies  which  on  occasion  are 
formed  by  everybody,  and  are  more  spontaneously  produced  by  the 
poets.  Gottfried  Keller's  Griiner  Heinrich  relates  in  an  episode  which 
is  undoubtedly  created  from  the  poet's  own  childhood,  how  when  in 
the  abc  class  he  was  painfully  taken  to  task  for  using  ugly  words 
which  he  accidentally  absorbed,  how  in  his  embarrassment  he  named 
some  place  and  name,  following  which,  to  further  questions,  a  more 
complicated  scene  emerged  with  all  possible  details,  which  he  believed 
was  an  experience  from  his  own  life. 

What  happened  here  to  the  future  poet  occurs  habitually  in  Pseudo- 
logia  Phantastica.  Pseudologues  have  a  vivid  phantasy,  they  invent 
for  themselves  some  fairy  story  about  princely  lineage  or  some  other 
desirability  and  act  upon  it.  In  contradistinction  to  confabulations 
and  memory  hallucinations,  the  real  worth  of  their  phantasies  be- 
comes conscious  to  the  pseudologues  as  soon  as  they  are  recalled  to 
them  by  the  events,  and  sometimes  even  without  this;  in  every  case 
a  part  of  the  fancies  are  just  lies.  Yet,  for  any  long  period  the 
pseudologues  are  capable  of  ignoring  the  fact  that  they  are  living  in 
a  dream  world.  This  circumstance,  with  a  great  talent  to  put  a  role 
into  operation,  which  for  inner  reasons  is  regularly  found  at  least  in 
all  cases  that  come  for  investigation,  gives  them  the  facility  to  de- 
ceive their  environments,  and  if  they  are  not  very  moral  they  are 
destined  to  become  panhandlers.  Pseudologia  phantastica  is  therefore 
a  general  anomaly  and  not  merely  one  of  memory.  The  following 
cases  will  serve  as  illustrations:  ^^ 

A  young  man  of  good  breeding  fancied  so  vividly  that  his  mother 
died,  that  he  rode  home  dressed  in  mourning  carrying  a  wreath  of 
flowers  of  his  mother's  funeral.  Another  young  man  had  a  quarrel  with 
a  friend.  He  then  pictured  to  himself  a  duel  with  his  antagonist  whom 
he  shot  dead,  and  that  he  informed  the  latter's  father  of  the  unfortu- 
nate outcome  of  the  duel.  I  found  one  prisoner  in  his  cell  projecting 
a  plan  for  an  English  park.  He  admitted  that  he  had  already  pre- 
pared in  his  mind  the  speech  he  was  to  deliver  to  his  dinner  guest 
on  the  occasion  of  the  first  hunting  party. 

Among  the  parafunctions  of  memory  one  may  mention  in  the  first 
place  the  identifying  memory  deceptions.  Even  the  healthy  person 
has  sometimes  the  feeling,  particularly  wh"en  fatigued,  that  he  had 

'^  Aschaffenburg,  Die  pathologischen  Schwindler,  Allgem.  Zeitschr.  f.  Psych. 
909,  Bd.  66,  p.  1073. 


GENERAL  PSYCHOPATHOLOGY  109 

already  experienced  something  that  happens  to  cross  his  mind  at  the 
time  being.  An  attempt  was  even  made  to  trace  such  deceptions  to 
the  idea  of  the  transmigration  of  the  soul.  It  occurs  more  frefjuently 
in  neurasthenics.  Now  and  then  this  manifestation  is  also  observed 
in  schizophrenics  and  epileptics,  who  are  usually  peeved  over  it  and 
imagine  that  some  comedy  is  performed  for  their  benefit.  A  schizo- 
phrenic that  I  have  known,  believed  for  a  long  time  that  whatever 
he  experienced  he  had  already  gone  through  in  exactly  the  same  way 
a  year  before.  An  epileptic  who  in  a  twilight  state  saw  in  everything 
that  happened  to  him,  especially  visits  and  the  doctor's  words,  a 
repetition  of  a  few  weeks  before,  finally  remarked  that  everything 
repeated  itself,  and  placed  the  actual  experiences  in  a  great  number 
of  former  twilight  states,  a  fact  which  at  the  time  caused  him  marked 
excitement. 

Just  as  the  memory  qualities  are  in  this  case  connected  with  ideas 
to  which  they  do  not  belong,  so  also  do  we  find  reminiscences  in 
cryptomnesias  which  have  lost  the  memory  qualities  and  appear  to  the 
patient  as  new  creations.  There  are  learned  men  who  at  first  nega- 
tively reject  every  new  idea  and  then  digest  it  consciously  or  uncon- 
sciously, and  finally,  accept  it,  if  it  suits  them,  but  then  absolutely 
forget  that  these  are  no  discoveries  of  their  own,  and  even  go  so  far 
as  to  present  them  as  new  to  the  very  people  who  discovered  them. 
Senile  patients  often  relate  a  story  at  a  social  gathering  as  new,  which 
they  have  heard  only  a  few  minutes  before  from  somebody  else  at  the 
same  gathering.  Frequently,  however,  the  cryptomnesia  embraces 
the  whole  wording.  In  the  beginning  of  this  century  an  art  critic  was 
once  accused  of  plagiarism  because  he  reproduced  word  for  word  a 
criticism  of  somebody  else.  The  whole  state  of  affair  points  that  it  must 
have  been  a  case  of  cryptomnesia.  Jung  has  also  demonstrated 
cryptomnesia  in  Nietzsche  who  verbally  put  a  paragraph  from 
the  Seeress  of  Prevorst  into  his  Zarathustra,  and  what  is  more,  in 
quite  a  senseless  connection.^^  Helen  Keller's  unconscious  repro- 
duction of  the  fable  of  the  Frost  King  caused  her  a  great  deal  of 
annoyance. 

As  reduplicative  memory  deception,  Pick  has  described  a  mani- 
festation sometimes  seen  in  organic  patients,  which  consists  in  the  fact 
that  the  patients  do  not  duplicate  the  actual  act  but  double  the  details 
of  it.    They  say  that  they  have  already  been  examined  in  the  ver>'' 

"  C.  G.  Jung,  Zur  Psychologie  und  Pathologie  sogenannter  okkulter  Phano- 
mene,  Stuttgart,  Mutze  1902  Especially  instructive  is  Flournoy's  "Des  Indes 
a  la  Planete  Mars,  Paris  and  Geneve  1900.  (Etude  sur  un  cas  de  Somnam- 
bulisme  avec  glossolalie.) 


no  TEXTBOOK  OF  PSYCHIATRY 

same  clinic  by  the  very  same  physician,  having  the  same  name,  there 
are  therefore,  two  such  physicians  and  clinics, 

5.    DISTURBANCES  OF  ORIENTATION 

Wernicke  divides  disturbances  of  orientation  into  autopsychic  or 
those  referring  to  the  individual's  person,  somatopsychic  or  those  re- 
ferring to  the  individual's  body,  and  allopsychic  or  those  referring 
to  the  outer  world.  This  differentiation  has  a  specific  meaning;  thus 
patients  in  alcoholic  deliria  are  never  autopsychically  disoriented, 
that  is,  they  can  give  a  good  account  of  their  personal  matters,  their 
residence,  occupation,  and  past  life,  whereas  allopsychically  they  ar€ 
usually  deeply  disoriented,  especially  as  to  time  and  place.  However, 
this  classification  fails  to  give  proper  emphasis  on  the  element  of  the 
situation  which  may  form  part  of  allopsychic  as  well  as  autopsychic 
orientation.  Instead  of  somatopsychic  disorientation  we  prefer  to 
speak  of  somatic  illusions  and  hallucinations. 

In  all  organic  mental  diseases  of  a  higher  grade,  the  primary 
auxiliary  functions  of  orientation,  perception,  memory,  and  attention 
are  affected,  and  in  addition  there  is  also  a  disturbance  of  the  com- 
prehensive orientation  itself.  Orientation  as  to  time  and  place,  and 
later  also  as  to  the  situation,  are  falsified.  The  patients  are  not  aware 
that  they  are  kept  in  an  institution,  or  of  the  reason  thereof,  nor  do 
they  recognize  as  such  the  doctors  who  are  treating  them.  Not  in- 
frequently one  observes  in  the  insane  asylum,  that  orientation  as  to 
situation  which  is  otherwise  less  liable  to  injury  is  falsified  before 
orientation  as  to  time.  This  is  due  to  the  fact  that  the  patients  do 
not  wish  to  be  in  such  a  place. 

Orientation  as  to  time  and  place  are  always  present  in  Schizo- 
phrenia; they  are  often  very  well  preserved  unless  interfered  with  by 
secondary  influences  such  as  delusions  and  hallucinations.  The  patient 
who  believes  he  is  Christ  usually  considers  himself  1900  years  old. 
For  affective  reasons  the  calendar  itself  is  often  directly  falsified. 
Places  are  nearly  always  correctly  recognized  by  clear  Schizophrenics. 
On  the  other  hand,  orientation  as  to  the  situation  is  in  most  cases 
incorrect,  at  least  in  interned  Schizophrenics.  The  patients  cannot 
comprehend  that  they  are  considered  sick,  they  believe  themselves 
unjustly  confined,  etc. 

Furthermore,  orientation  can  be  falsified  in  all  its  relations  by 
hallucinations  and  illusions.  If  a  patient  sees  hell  instead  of  the 
hospital  ward,  or  a  devil  instead  of  an  attendant,  he  cannot  imagine 
himself  in  an  insane  asylum.    The  strange  part  of  it  is,  that  in  such 


GENERAL  PSYCHOPATHOLOGY  111 

states  of  schizophrenia,  hardly  ever  in  other  diseases,  the  correct 
orientation  mostly  accompanies  the  false  one;  one  might  say  that 
there  is  a  double  orientation.  Depending;  on  the  constellation  the 
patient  uses  now  one,  then  the  other  orientation,  and  often  both 
together. 

In  all  states  of  vivid  hallucinations  which  conceal  the  real  per- 
ceptions, thinking  is  also  disturbed,  often  in  a  very  profound  manner, 
as  for  example  in  epileptic  twilight  states  where  it  is  sometimes  more 
pronounced  than  in  our  dreams.  In  some  cases  the  disturbance  of 
thinking  seems  to  be  the  chief  cause  of  the  disorientation,  as  in  cases 
of  confusion  (amentia).  That  a  schizophrenic  delirium  should  appear 
to  last  thousands  of  years,  and  a  dream  of  a  few  seconds  many  hours, 
fits  in  well  with  the  absolutely  changed  course  of  the  psychic 
mechanisms. 

Disorientation  as  to  time  and  place  is,  therefore,  one  of  the  most 
constant  partial  symptoms  of  all  disturbances  of  consciousness,  such 
as  deliria,  crepuscular  states,  confusions,  amentias,  and  other  states. 
Not  seldom  we  also  find  here  some  autopsychic  disturbance  (referring 
to  the  person) . 

6.    DISTURBANCES  OF  CONSCIOUSNESS 

Under  the  expressions  "Disturbance  of  Consciousness"  and  "Cloud- 
ing of  Consciousness,"  which  do  not  fit  in  with  the  rest  of  our  termi- 
nology, but  for  which  we  have  not  yet  found  substitutes,  we  conceive 
a  number  of  anomalies  in  which  the  general  relationship  of  the  psychic 
processes,  usually  including  orientation,  is  disturbed,  or  in  which 
psychic  processes  are  forcibly  hindered  from  coming  to  conscious- 
ness." The  first  type  of  disturbance  is  especially  found  in  the  states 
of  Confusion  mentioned  above,^^  which  may  arise  from  very  different 
fundamental  disturbances.  Marked  confusion  with  numerous  halluci- 
nations was  also  designated  as  Amentia.  Kraepelin  uses  this  term 
for  a  definite  morbid  picture.^^  Deliria  and  Timlight  or  crepuscular 
states  are  concepts  everywhere  used,  even  though  they  are  very  dif- 
ferently defined  by  different  authors,  and  not  clearly  differentiated 
from  each  other,  nor  definitely  limited. 

What  one  calls  Deliria  are  mostly  states  of  incoherent  thinking 
combined  with  hallucinations  and  delusions,  which  show  a  certain 
activity  and  run  a  rapid  course.    They  usually  accompany  other  dis- 

'^The  "conscience"  of  the  French  is  a  broader  term  than  our  modern  con- 
sciousness.   Even  simple  delusions  are  "troubles  de  la  conscience." 
=^  Cf.  p.  86. 
'^Cf.  Special  part. 


112  TEXTBOOK  OF  PSYCHIATRY 

eases,  such  as  infections,  fevers,  exhaustions,  toxic  states,  and  sud- 
denly appear  in  the  dark  room  in  cases  of  diseases  of  the  eye.  But 
in  a  certain  sense,  some  states  of  Schizophrenia  and  manic  depressive 
insanity,  may  also  be  designated  as  deliria.  Disturbances  of  con- 
sciousness in  febrile  diseases  were  all  wont  to  be  designated  as  deliria, 
although  many  of  them  clearly  show  connected  ideas  along  the  line  of 
complexes  and,  therefore,  rather  belong  to  the  "twilight  states."  In 
the  newer  German  psychiatry  the  term  "delirium"  most  frequently 
stands  for  ''Delirium  tremens."  The  memory  of  deliria  is  usually 
imperfect  or  totally  absent.*" 

The  name  Twilight  State  suggests  especially  a  systematic  falsifica- 
tion of  the  situation.  He  who  is  familiar  with  these  states  finds  sense 
and  a  more  or  less  logical  connection  in  the  acts  of  the  patient.  The 
onset  and  termination  of  twilight  states  are  most  often  sudden,  the 
duration  is  brief,  lasting  from  a  few  minutes  to  a  few  days,  rarely  for 
weeks  or  months. 

In  the  (less  frequent)  oriented  twilight  states  the  associations  are 
narrowed.  There  seems  to  be  present  only  a  single  purpose  striving 
to  accomplish  what  is  necessary,  while  the  rest  of  the  personality,  at 
least  to  the  extent  that  it  runs  counter  to  this  purpose,  does  not  exist. 
The  patients  act  in  a  definite  direction,  they  run  away,  take  a  journey, 
make  a  purchase,  commit  a  crime  which  otherwise  would  be  foreign  to 
them;  they  do  all  that  without  any  regard  for  themselves  or  others, 
even  though  at  times,  especially  in  the  case  of  forbidden  acts,  they 
endeavor  to  protect  themselves  against  discoveries.  During  this  period 
if  they  can  be  observed  they  usually  strike  one  as  abnormal ;  at  times, 
however,  they  can  use  correctly  ordinary  means  of  intercourse,  can 
associate  with  fellow  travelers,  and  can  even  visit  relatives,  without 
betraying  their  condition. 

The  ordinary  disoriented 'twilight  states  present  themselves  quite 
differently  and  yet,  as  daily  transitions  show,  they  are  only  an  exag- 
geration of  the  preceding.  In  spite  of  a  certain  coherence,  which  might 
be  compared  with  a  dream,  thinking  is  not  clear  or  it  may  even  be 
confused.  The  connection  with  the  outer  world  is  altogether  inter- 
rupted or  falsified  by  illusions  and  hallucinations  of  the  visual  and 
auditory  types,  especially  the  former.  The  patients  see  robbers,  ani- 
mals, devils,  or  the  Almighty  with  many  saints;  they  actually  believe 
themselves  in  a  dream-like  situation  and  act  accordingly.  As  in  the 
dream  the  content  of  the  twilight  ideas  may  be  anxious,  indifferent,  or 

*'The  French  conception  of  delirium  is  much  broader.  They  even  call 
delusions  occurring  in  clear  consciousness  delirium.  Bouffee's  delirantes  are, 
according  to  Magnan,  transitory  deliria  in  his  "degenerates." 


GENERAL  PSYCHOPATHOLOGY  113 

rapturous.  Anxious  and  hostile  illusions  provoke  the  patients  to  acts 
of  violence;  killing  even  several  people  is  not  uncommon.  Sexual  ex- 
citements lead  to  rape  and  murder.  An  epileptic  set  fire  to  his  work- 
shop in  the  belief  that  he  was  lighting  a  fire  under  a  lime  pan.  States 
of  rapture  are  designated  as  ecstasies.  In  such  states  association  with 
the  outer  world  is  so  completely  interrupted  that  an  absolute  analgesia 
exits.  The  patients  see  the  heavens  open,  associate  with  the  saints, 
hear  heavenly  music,  experience  wonderful  odors  and  tastes  and  an 
indescribable  delight  of  distinct  sexual  coloring  that  pervades  the 
entire  body. 

Some  twilight  states  have  a  definite  purpose  such  as  to  represent 
illnesses  and  the  like,  of  which  the  best  known  type  is  the  so-called 
Ganser  state.  The  varieties  of  these  forms  are  indicated  under  the 
Syndromes. 

The  causes  of  twilight  states  are  very  varied.  Many  have  their 
origin  in  an  affective  necessity ;  hysterics  and  schizophrenics  turn  away 
from  reality  because  it  has  become  unbearable.  An  engagement  which 
has  been  broken  in  reality  continues  in  the  twilight  state  and  leads 
to  marriage.  Some  hysterical  twilight  states  repeat  hallucinatorily  an 
emotionally  accentuated  event,  especially  of  an  ambivalent  nature, 
e.g.  a  sexual  attack.  Less  frequently  the  delights  of  ecstasy  can  be 
conjured  up.  The  basis  of  twilight  states  are  the  hysterical,  epileptic 
or  schizophrenic  disposition,  toxic  conditions,  especially  pathological 
intoxication,  also  sleep,  as  pavor  nocturnus,  somnambulism  and  hyp- 
nogogic  intoxication,  less  frequently  it  is  migraine,  concussion  of  the 
brain,  and  brain  disturbances  after  hanging,  occasionally  it  may  also 
be  caused  by  severe  excitements  as  in  the  case  of  psychopathies.  In 
hysteria  the  entire  mechanism  is  psychogenetic ;  in  the  toxic  states  of 
epilepsy  and  schizophrenia,  it  is  the  brain  disturbances  which  usually 
furnish  the  necessary  factor.  All  these  states  produce  clear  thinking 
which  becomes  systematized  as  a  result  of  affective  aims,  in  conse- 
quence of  which  the  disturbance  assumes  the  form  of  a  twilight  state. 
The  disturbance  of  thought  then  has  a  twofold  origin,  one  in  the  toxic 
confusion,  the  other  in  the  systematic  formation  with  its  misunder- 
standing of  reality.  It  is  self-evident,  that  in  epilepsy  as  well  as  in 
schizophrenia  the  relation  of  the  two  causes  may  be  entirely  different. 
There  are  extreme  cases  in  both  directions,  on  the  one  hand  conditions 
in  which  the  organic  completely  dominates  the  picture,  and  on  the  other 
hand  those  which  are  of  an  entirely  psychogenetic  (hysterical)  char- 
acter and  in  which  acute  changes  of  the  fundamental  condition  play  no 
part.  Where  primary  anxiety  exists,  as  is  often  the  case  in  epilepsy, 
the  content  of  the  delusion  is  colored  in  this  sense. 


114  TEXTBOOK  OF  PSYCHIATRY 

Naturally,  we  often  observe  very  mild  twilight  states  and  deliria, 
in  which  the  thought  process  is  only  more  or  less  unclear.  These  mild 
forms  together  with  deliria  and  twilight  states  may  be  called  pro- 
visionally turbid  states. 

There  is  still  another  gradual  weakening  of  consciousness  which 
is  shown  by  the  fact  that  external  stimuli  must  be  endowed  with  an 
abnormally  great  intensity  in  order  to  become  conscious.  Mild  states 
of  this  sort  are  called  cloudiness,  a  name  that  may  also  designate  light 
grades  of  the  twilight  states.  Similar  states  that  are  somewhat  deeper 
and  especially  those  in  which  movements  are  retarded  are  designated 
as  somnolence;  those  in  which  only  stronger  stimuli  produce  reactions 
are  called  torpor  or  sopor;  and  those  in  which  there  is  no  longer  any 
reaction  are  called  coma.  In  the  last  condition  one  assumes  that  there 
is  a  state  of  actual  unconsciousness,  i.e.,  an  absence  of  conscious 
psychisms.  This  is  naturally  something  entirely  different  from  the 
falsely  designated  unconsciousness  in  a  twilight  state. 

In  all  these  disturbances  the  field  of  consciousness,  that  is,  the  num- 
ber of  simultaneous  ideas,  is  greatly  diminished;  in  the  twilight  states 
this  is  more  or  less  systematic,  in  other  conditions  it  is  diffuse.*^ 

There  is  also  a  purely  functional  attempt  to  keep  occurrences  out 
of  consciousness.  When  attention  makes  way  for  a  certain  group  of 
ideas  it  blocks  at  the  same  time  all  others.  In  a  cheerful  mood  un- 
pleasant thoughts  are  automatically  kept  away.  In  melancholia  cheer- 
fulness cannot  even  be  thought  of.  The  katathymic  exclusion  of  un- 
bearable complexes  from  consciousness  (repression)  belongs  to  this 
category.  In  all  these  cases  the  functions  which  are  not  admitted 
to  consciousness  may  be  entirely  impeded  or  they  may  lead  an  un- 
conscious existence.*^ 

Sleep  is  a  kind  of  physiological  disturbance  of  consciousness  which 
also  gives  occasion  for  several  pathological  symptoms.  I  do  not  know 
whether  or  not  one  always  dreams  in  sleep.  In  our  present  state 
of  knowledge  the  forms  of  association  in  dreams  are  the  same  as  in 
schizophrenia.  The  psychopetal  functions  usually  are  extremely  re- 
stricted in  sleep,  partly  in  such  a  way  that  only  strong  stimuli  arouse 
reactions,  partly,  and  this  is  more  important,  in  such  a  way  that  the 
main  part  of  the  stimuli  is  shut  off  regardless  of  its  intensity,  and 
its  place  is  taken  by  a  smaller  group,  which  is  generally  or  under 
certain  constellations  especially  important.  Thus  a  nurse  sleeps 
through  a  great  noise  but  is  awakened  by  a  slight  respiratory  change 
in  her  patient.     The  psychofugal  connection  with  the  outer  world, 

*^  For  alternating  consciousness  Cf .  Personality. 
"  Comp.  the  Unconscious,  p.  8. 


GENERAL  PSYCHOPATHOLOGY  115 

at  least  as  far  as  concerns  the  voluntary  muscular  system,  is  usually 
limited  to  movements  that  make  respiration  easy,  change  uncomfort- 
able positions,  ward  off  stimuli  from  insects,  etc.  Movements  that 
are  not  carried  out  are  falsely  conceived  through  kinaesthetic  halluci- 
nations, except  in  nightmares,  where  the  paralysis  is  felt,  and  what 
is  not  quite  the  same  thing,  the  interruption  between  volition  and 
motility  comes  into  consciousness. 

Falling  asleep  is  the  result  of  an  influence,  or  a  special  act,  which 
is  put  in  operation  by  the  predisposition  to  fatigue,  a  feeling  which  is 
psychically  determined.  Perhaps  the  only  thing  of  importance  for 
psychotherapy  is  the  psychic  participation  in  the  initiation  of  sleep. 
The  essential  thing  is  the  "suggestion  of  sleep."  To  be  sure,  energetic 
mental  occupation  in  the  evening  may  for  a  time  hinder  the  command 
to  sleep.  But  ordinarily,  it  is  the  affects  that  exclude  sleep.  For 
example,  one  is  particularly  apt  to  remain  awake  when  one  is  pleas- 
antly or  unpleasantly  excited,  when  one  is  afraid  of  not  being  able 
to  sleep,  or  when  one  "imagines"  himself  disturbed  by  a  definite 
sensory  impression.  Here  the  sensory  impression  has  really  no  signifi- 
cance, compared  with  the  psychic  attitude.  The  psychotherapist  must 
firmly  maintain  that  when  some  one  cannot  sleep,  let  us  say,  because 
his  neighbor  snores,  that  it  is  his  own  attitude  and  not  the  neighbor's 
snoring  that  is  the  cause  to  be  considered.  One  can  sleep  in  the  worst 
noise  if  one  is  able  to  assume  a  proper  attitude,  and  at  the  same  time 
one  can  be  awakened  by  the  slightest  sensory  impression  for  which 
there  is  an  association  readiness.  Millions  sleep  through  the  street 
noises  of  the  metropolis.  One  of  the  most  important  neurotic  dis- 
turbances of  sleep  is  undoubtedly  based  on  the  fact  that  emotionally 
accentuated  complexes,  which  are  more  or  less  repressed  by  the  day's 
work,  make  themselves  felt  as  soon  as  purposive  thinking  ceases. 

What  the  recuperative  function  of  sleep  is,  we  do  not  know.  At 
all  events  it  is  under  a  special  influence,  because,  in  states  of  depres- 
sion, for  example,  one  can  dispense  for  many  months  with  sleep,  in 
the  sense  of  disturbance  of  consciousness  and  association,  without 
apparent  results,  while  an  artificial  insomnia  of  only  eight  days  is 
certainly  fatal.  Moreover  a  partial  insomnia  has  few  or  no  imme- 
diate ill  effects,  if  one  succeeds  in  lying  quiet  and  not  exhausting  one- 
self in  the  "struggle  for  sleep." 

The  dream  is  classed  with  the  twilight  states  because  ordinarily  it 
does  not  influence  conduct.  Nevertheless  in  the  sleep  of  no  person 
are  the  connections  with  the  outer  world  maintained  only  through 
the  merely  necessary  centrifugal  and  centripetal  impulses.  Through 
groaning,  twisting,  and  through  many  somewhat  uncoordinated  move- 


116  TEXTBOOK  OF  PSYCHIATRY 

ments  and  similar  expressions  one  satisfies  even  in  sleep  some  internal 
or  external  requirements.  A  slight  increase  of  these  normally  existing 
motor  commands  permits  the  release  of  any  acts  corresponding  to 
dream  images,  and  leads  to  twilight  states  of  somnabulism,  hypnogogic 
intoxication,  and  pavor  nocturnus. 

Somnambulism  occurs  in  nervous  persons  of  all  types,  in  epileptics, 
and  to  a  mild  degree,  at  times  in  people  who  must  be  considered 
healthy;  this  is  especially  the  case  in  youth.  There  are  all  sorts  of 
transitions  from  simple  movements  and  mumbling  in  sleep  to  more 
complex  acts  as  well  as  walking  which  sometimes  takes  place  on  the 
roof.  Most  frequently  such  little  acts  are  performed  that  correspond 
to  the  daily  occupation;  these  are  sometimes  senseful  and  sometimes 
senseless.  Complexes  may  also  find  expression  in  somnambulism 
(Lady  Macbeth). 

Hypnogogic  intoxication  (Schlaftrunkenheit)  may  occur  during 
spontaneous  awakening  in  people  who  seem  perfectly  well,  but  more 
frequently  it  follows  a  rough  waking,  which  generates  a  dream,  and 
induces  motility  before  the  dream  disappears.  In  rare  cases  some- 
thing clumsy  is  then  performed,  indeed,  under  the  influence  of  terrifying 
ideas  an  attack  or  murder  may  be  perpetrated.  A  variety  of  sleep 
intoxication  which  is  especially  frequent  in  children  is  pavor  noc- 
turnus. It  usually  manifests  itself  in  the  beginning  of  the  night  when 
the  little  ones  start  with  an  anxious  cry  and  despite  all  attempts  to 
wake  or  quiet  them,  become  mentally  clear  only  after  several  minutes 
or  even  a  longer  time.  The  syndrome  is  often  altogether  psychically 
determined,  in  other  cases  it  is  favored  or  absolutely  induced  by 
respiratory  difficulties.  The  twilight  states  of  sleep  are  also  regularly 
followed  by  amnesias. 

"Clear  Mindedness"  ("Besonnenheit") 

In  contrast  with  disturbance  of  consciousness  there  is  "clear 
mindedness,"  a  concept  that  is  plain  to  all,  although  it  cannot  be  quite 
defined.  In  states  of  clear  mindedness  every  disturbance  of  con- 
sciousness is  lacking,  orientation  is  good,  the  affects  produce  neither 
unconsidered  acts  nor  stupor.  The  most  inhibited  melancholic  can 
think  normally  within  the  range  of  ideas  accessible  to  him,  and  can 
orient  himself,  he  is  so  to  speak,  clear  minded.  The  most  chronic 
states  of  schizophrenia  do  not  lack  clearmindedness,  although,  under 
certain  circumstances,  the  patients  act  in  an  entirely  senseless  way. 
The  major  part  of  the  thinking  function  runs  along  smoothly;  orienta- 
tion especially  is  good,  and  there  is  always  a  possibility  of  discussing 
many  things  sensibly  with  the  patient.    The  outward  indications  of 


GENERAL  PSYCHOPATHOLOOY  117 

clear  mindedncss,  according  to  Jasper,  are  orientation,  and  the  ability 
to  reflect  on  questions  and  to  take  some  notice  of  them. 

The  concept  is  important  because  in  clearmindedness  identical 
symptoms  have  an  entirely  different  significance  than  in  states  of 
disturbance  of  consciousness.  In  twilight  states  the  most  confused 
delusions  indicate  nothing  concerning  the  prognosis,  somatic  hallucina- 
tions indicate  almost  as  little.  In  clear  mindedness  both  symptoms 
point  to  a  grave  condition,  the  latter  especially  to  a  schizophrenic 
condition. 

7.    DISTURBANCES  OF  AFFECTIVITY 

Since  the  affective  dispositions  fluctuate  greatly  in  different  people, 
they  also  most  readily  cross  the  borderline  of  the  "normal."  The 
so-called  psychopaths  are  really  nearly  all  exclusively  or  mainly 
thymopaths.  Furthermore,  since  affectivity  dominates  all  other  func- 
tions, it  assumes  a  prominent  role  in  psychopathology  generally,  even 
in  slight  deviations,  not  only  on  account  of  its  own  morbid  mani- 
festations, but  even  more  because  in  disturbances  in  any  sphere,  it 
is  the  affective  mechanisms  that  first  create  the  manifest  sj'mptoms. 
What  we  call  psychogenic  is  mostly  thymogenic.  The  influence  of  the 
affects  on  the  associations  produces  delusions,  systematic  splittings  of 
personality,  and  hysteroid  twilight  states;  repressed  pain  is  the  source 
of  most  neurotic  symptoms,  while  displacements  and  irradiations 
produce  compulsive  ideas,  obsessive  acts,  and  similar  mechanisms. 
Ambivalent  feeling  complexes,  that  is,  viewed  from  the  active  side, — 
inner  conflicts,  which  the  individual  cannot  settle  but  must  repress, 
prove  especially  pathogenic.  To  avoid  repetitions  the  causal  signifi- 
cance of  the  affects  will  here  be  passed  over,  and  only  the  etiolog>' 
of  certain  symptoms  will  be  briefly  considered.  Only  the  phenome- 
nology of  the  affective  disturbances  will  follow  here. 

Many  affective  disturbances  come,  as  it  were,  from  within,  from 
the  physiology  of  the  brain  and  from  the  general  chemism.  Here  one 
is  perfectly  right  in  thinking  of  the  "inner  secretions''  in  the  widest 
sense,  without  knowing  anything  definite  about  them.  To  this  one 
may  add  the  affective  bases  of  melancholia  and  mania,  the  euphoria 
of  chronic  alcoholics,  and  most  of  the  moody  states  of  epileptics  and 
imbeciles,  and  naturally  also  the  congenital  abnormal  emotional  states. 
The  last  may  have  a  significance  of  their  own,  as  in  the  case  of  "chronic 
moods,"  or  ma}''  be  the  foundation  on  which  other  diseases  originate. 
To  become  an  hysteric  or  paranoiac  one  needs  a  distinct  aft'ective  con- 
stitution which  is  usually  congenital.     Such  morbid  constitutions  are 


118  TEXTBOOK  OF  PSYCHIATRY 

almost  always  exaggerations  of  the  character  variations  of  the  normal 
type  or  "temperaments." 

Other  affective  disturbances  are  qualitatively  correct  but  quantita- 
tively exaggerated  reactions  to  an  experience,  which  usually  have  their 
origin  in  the  constitution.  Thus  a  mother  loses  her  child,  and  does 
not  recover  from  the  blow  for  years,  remaining  in  mourning  all  the 
time.  She  shows  a  morbid  protraction  of  the  affect.  Or  she  reacts 
so  strongly  to  her  misfortune  that  she  can  no  longer  work  or  eat,  is 
entirely  absorbed  in  the  anguish  and  can  in  no  way  be  distinguished 
from  a  melancholic.  Here  one  sees  a  morbid  intensity  of  the  affect. 
In  this  way  certain  anxiety  affects  may  lead  to  affective  stupor  ^^  and 
confusion, — manifestations  that  make  the  examination  of  children  and 
oligophrenics  particularly  difficult,  and  often  lead  into  entirely  false 
trails. 

Reactions  in  themselves  normal  may  appear  morbid  because  the 
intellectual  process  on  which  they  are  based  is  abnormal.  A  paranoiac 
believes  that  he  has  made  a  revolutionary  discovery  which  makes  him 
emotionally  exalted,  or  he  considers  himself  persecuted  and  becomes 
irritated.  In  both  cases  the  affects  are  normal  reactions  to  a  morbid 
idea;  in  itself  the  formation  of  the  affect  is  normal.  In  the  same 
way  there  is,  for  example,  a  secondary  apathy  in  organic  cases,  who 
do  not  understand  many  experiences  and,  therefore,  naturally  cannot 
react  to  them.  As  soon  as  they  grasp  the  true  significance  of  any- 
thing the  same  patients  react  to  it  in  a  very  active  manner. 

Morbid  irradiations  and  affective  displacements  are  secondary  dis- 
turbances in  an  entirely  different  sense.  This  is  shown  in  the  following 
examples : 

The  patient  feels  disgust  and  anxiety  at  hornlike  soup  ingredients 
and  other  things  shaped  like  horns  because  she  was  once  frightened 
by  a  bull  whose  genitals  and  horns  particularly  impressed  her.  A 
schizophrenic  woman,  a  patient  of  v.  Speyer  hated  her  landlord  be- 
cause he  had  cheated  her  husband.  When  she  was  taken  with  labor 
pains  in  an  isolated  country  place,  instead  of  a  mid-wife  the  wife  of 
the  landlord  had  to  assist  her.  The  hate  was  transferred  from  the 
landlord  to  his  wife,  and  from  the  latter  to  her  own  child  which  she 
tortured  to  death. 

Most  affective  disturbances  are  transient  episodes.  Those  which 
continue  are  usually  congenital,  less  frequently  acquired,  as  the 
chronic  euphoria  of  alcoholics,  the  lability  and  some  persisting  euphoria 
or  depressive  states  in  organic  cases,  as  well  as  the  perseverance  and 
intensity  of  the  affects  in  epileptics. 
"Cf.  p.  80. 


GENERAL  PSYCHOPATHOLOGY  119 

Morbid  Depression 

In  general  depression,  all  experiences,  inner  and  outer,  are  toned 
with  psychic  pain  of  various  kinds.  The  milder  cases  resemble 
normal  "downheartedness."  It  is  not  so  easy,  however,  to  read  one- 
self into  the  affective  situation  of  the  profound  melancholic.  He 
has  lost  everything  that  was  of  value  to  him,  and  nevertheless  he 
expects  still  worse  for  himself  and  those  he  loves,  the  worst  that  one 
can  think  of.  Through  "diversion,"  i.e.  an  increase  of  sense  impres- 
sions, which  are  really  only  unpleasantly  toned,  the  pain  is  usually 
increased,  except  in  those  cases  where  the  feeling  that  the  patient 
does  not  feel  well  anywhere,  leads  to  a  continuous  change  of  environ- 
ment. In  many  cases  perceptions  take  on  the  character  of  strange- 
ness, of  uncanniness,  and  monotony;  optical  impressions  are  double 
dyed  gray,  things  seem  to  stand  crooked,  and  foods  lack  their  peculiar 
flavor.  Thinking,  in  itself,  is  not  only  colored  by  unpleasant  feelings, 
but  proceeds  with  difficulty,  and  only  ideas  of  a  painful  content  can 
be  thought  out.  Thoughts  of  a  pleasant  content  are  flighty  and 
transient,  leaving  no  influence  on  deliberation  and  the  general  con- 
dition. Only  with  great  difficulty  can  the  patient  resolve  to  act,  and 
when  he  succeeds  in  making  a  movement,  it  is  with  great  effort. 

The  mental  stream  is  inhibited,**  it  runs  more  slowly  and  the 
patient  must  exert  effort  to  think  out  anything;  a  change  of  the 
ideas  requires  exertion  or  is  even  impossible.  The  patients  always 
fall  back  on  the  same  ideas  of  a  sad  content  or  they  never  get  rid 
of  them  and  always  carry  with  them  the  same  desperate  thoughts 
(Monideism) . 

Among  the  varieties  of  depression,  of  which  we  mention  only  grief, 
desperation,  and  remorse,  anxiety  occupies  a  particular  place.  To 
be  sure,  it  is  often  combined  with  the  common  forms  of  depres- 
sion so  that  it  merely  complicates  the  latter.  Anxiety  may  also 
appear  in  isolated  form,  which  accounts  for  the  fact  that  starting 
from  different  viewpoints  some  authors  wish  to  differentiate  an  abso- 
lute anxiety  psychosis  and  an  anxiety  neurosis  as  special  forms  of 
disease.  Anxiety  undoubtedly  has  different  sources.  In  many  cases 
it  is  plainly  connected  with  respiratory  difficulties  as  seen  in  dis- 
eases of  the  heart,  in  the  respiratory  organs,  and  in  the  blood.  Further- 
more, anxiety  is  undoubtedly  connected  in  some  way  with  sexuality, 
a  fact  which  we  knew  for  a  long  time  but  which  Freud  first  made 
clearer.  Stimulated  but  unsatisfied  sexuality  leads  to  various  forms 
of  anxiety.    Frend's  conception  is  that  the  sexual  tension,  or  the  sexual 

**  Cf.  p.  74. 


120  TEXTBOOK  OF  PSYCHIATRY 

affect,  is  converted  into  anxiety,  which  may  not  be  right,  although 
sexual  satisfaction  maj^  under  certain  circumstances  remove  anxiety, 
and  although  anxiety  appearing  in  attacks,  as  is  more  generally  as- 
sumed, may  be  converted  into  other  syndromes,  such  as  inordinate 
hunger,  attacks  of  perspiration,  asthmatic  attacks,  diarrhoea,  dizzi- 
ness and  similar  symptoms.  We  also  know  that  normal  sexuality  has 
an  anxiety  component  and  that  not  seldom  orgasms  are  generated  by 
anxious  situations  such  as  hurrying  to  catch  a  train,  scolding  from 
a  teacher  in  school,  and  difficult  tasks.  In  many  cases  of  psychoses 
connected  with  anxiety  we  see  an  irresistible  impulse  toward  onanism 
that  disappears  with  the  affect.  But  there  must  be  other  patho- 
logic sources  of  anxiety.  Wherever  depression  in  general  originates 
from  physical  processes,  which  we  do  not  as  yet  know,  anxiety  too, 
may  be  generated,  at  least  as  far  as  we  can  judge  at  present; 
in  other  words,  in  all  states  of  melancholia  of  the  most  diverse 
diseases. 

In  a  more  striking  manner  than  the  other  affects,  anxiety  may 
exist  without  any  association  with  ideas:  The  patient  may  feel 
anxiety  without  knowing  why,  and  be  absolutely  certain  that  there 
is  no  ground  for  it  ("free  floating  anxiety").  In  many  cases  anxiety 
itself  creates  the  ideas  to  which  it  becomes  attached  and  which  it 
apparently  conditions.  In  most  cases,  however,  one  can  easily  dem- 
onstrate that  such  ideas  are  secondary;  the  anxious  patient  seizes 
on  something  that  might  produce  anxiety  such  as,  an  uncertain 
financial  condition,  an  insignificant  symptom  of  a  bodily  disturbance 
in  himself  or  others,  or  on  any  mistake  that  he  made  in  the  past; 
and  even  when  circumstances  can  convince  him  that  the  ideas  were 
wrong  the  anxiety  does  not  improve  in  consequence  but  it  attaches 
itself  to  a  new  idea.  Often  it  creates  one  as  an  anxiety  delusion  from 
pure  fancy  without  any  external  connection. 

Katathymic  anxiety  referring  to  a  particular  member  of  the  family, 
present  in  normal  and  abnormal  individuals,  is  as  a  rule  the  expres- 
sion of  a  repressed  wish  that  this  member  should  be  dead.  A  latent 
schizophrenic  woman  had  a  child  by  her  husband  whom  she  did 
not  love.  Her  anxiety  was  soon  noticed  even  by  the  midwife  when 
she  expressed  the  idea:  "I  should  only  wish  that  nothing  happen 
to  the  child!"  A  few  months  later  she  poisoned  it.  A  young  woman 
shows  her  illness  through  excessive  anxiety  for  her  mother.  As  soon 
as  her  mother  has  gone  out,  she  has  to  stand  at  the  window  to  see 
that  nothing  has  happened  to  her,  or  to  see  if  she  is  coming  back.  She 
is  strongly  attached  to  her  father  and  unconsciously  jealous  of  her 
mother. 


GENERAL  PSYCHOPATHOLOGY  121 

Anxiety  is  more  frequently  and  nnore  visibly  accompanied  by 
physical  symptoms  than  most  of  the  other  affects.  It  is  especialiy 
often  associated  with  an  increased  cardiac  tone  wliich  is  felt  in  the 
chest  as  something  heavy,  pressing  and  often  also  something  painful; 
these  feelings  may  be  present  even  when  the  by  no  means  un- 
common palpitation  is  absent.  As  in  angina  pectoris  the  pain  may 
even  irradiate  into  the  left  arm.  In  the  abdomen,  too,  a  rolling  or 
pulsing,  or  a  hot  stream  may  be  felt,  or  the  latter  may  appear  to 
rise  to  the  head,  where  other  bad  feelings,  such  as  knocking,  press- 
ing, and  fullness  may  exist.  "The  Anxiety"  is  often  localized  in 
the  place  where  one  has  the  greatest  sensation;  thus  one  speaks  of 
praecordial  anxiety,  which  is  the  most  frequent  concomitant  of  all 
depressions,  or  of  head  anxiety,  etc. 

Depression  in  general  usually  evinces  distinct  physical  symptoms. 
The  entire  turgor  vitalis  is  diminished,  the  patients  appear  older  than 
before,  and  the  metabolism  and  appetite  become  decreased.  The  mus- 
cular tone,  especially  of  the  extensors  and  abductors,  is  decreased, 
the  latter  move  with  greater  effort  than  their  opponents,  and  all  show 
as  little  activity  and  are  as  slow  as  possible.  As  a  result,  the 
patient's  posture  becomes  uniform,  languid,  and  bowed,  and  mani- 
fests a  tendency  to  draw  in  the  limbs.  The  handwriting  usually  shows 
a  tendency  to  slant  the  letters  downwards. 

In  some  cases,  especially  those  showing  anxiety,  instead  of  motor 
retardation  there  is  a  desire  to  express  or  get  rid  of  the  inner  ten- 
sion through  movements  {Melancholia  agitata).  In  contrast  with  the 
common  cases  of  melancholia  some  patients  have  no  feeling  of  fatigue 
and  run  around  continuously  and  when  permitted  take  tireless 
walks.  In  contradistinction  to  the  normal  we  see  more  rarely, 
that  morbid  anxiety  retards  movement  and  the  psychic  processes 
generally. 

Respiration  is  easily  disturbed,  in  that  inspiration  becomes  less 
free,  and  connected  with  this  are  the  frequent  feelings  of  oppression. 
The  ipidse  is  mostly  full  and  small,  and  the  artery  contracted.  Anxiety 
increases  the  blood  pressure. 

An  increased  tone  of  the  throat  inuscles  very  often  causes  an  annoy- 
ing feeling  of  strangulation  causing  the  patient  to  refuse  nourishment; 
it  also  produces  pressure  in  the  chest.  In  addition  all  other  possible 
dysaesthesias  may  accompany  depression. 

Depressions  occur  in  the  most  varied  psychoses.  The  tendency 
to  it  increases  with  age,  and  wdth  increasing  vascular  disturbances 
there  is  more  anxious  excitation.  Depression  is  the  essential  symp- 
tom in  all  states  of  melancholia,  and  above  all  in  those  of  manic 


122  TEXTBOOK  OF  PSYCHIATRY 

depressive  insanity.  Besides  these,  there  are  certainly  depressions  of 
other  kinds  which  we  cannot  as  yet  characterize.  Anxiety  is  an 
important  concomitant  of  phobias,  obsessive  ideas  and  obsessive  acts. 

The  Pathological   Elated  Mood    (Exaltation,   Euphoria) 

We  can  differentiate  two  kinds  of  exaltation  that  are,  however, 
connected  by  all  the  intermediate  stages.  In  simple  euphoria  one 
enjoys  the  world  and  one's  own  existence  in  a  particularly  lively 
way;  sensations  and  thoughts  are  pleasantly  accentuated.  Among 
the  healthy  of  this  type  we  have  the  sunny  dispositions,  while  among 
the  sick  we  see  some  paretics  not  really  of  the  manic  type,  less  often 
cases  of  senility,  and  at  times,  also  epileptics  in  a  euphoric  mood 
{morbid  euphoria) .  In  the  second  form,  which  deserves  more  the  name 
of  exaltation  in  a  narrower  sense,  we  also  see  self-consciousness  and 
with  it  an  enormous  enhancement  of  desires  and  claims.  This  nat- 
urally results  in  conflicts  and  leads  regularly  to  severe  outbursts  of 
anger.  The  conditions  therefore,  in  which  one  sees  this  symptom  to- 
gether with  flight  of  ideas  and  pressure  activity,  are  designated 
as  mania  and  the  affective  state  as  manic  depression.  In  a  somewhat 
milder  form  and  without  the  flight  of  ideas  we  see  this  exaltation  in 
the  common  alcoholic  euphoria. 

Naturally,  the  pleasant  accentuation  may  here,  too,  evince  various 
shades  such  as  cheerfulness,  lack  of  restraint,  aesthetic  enjoyment, 
and  a  general  ineffable  feeling  of  delight;  the  last  is  especially  ob- 
served in  paresis.  The  blissful  feeling  accompanying  the  ecstasy  is 
principally  something  quite  different  than  manic  euphoria,  both  in 
the  quality  of  feeling  as  well  as  in  relation  to  the  mechanism  of  its 
origin,  which  in  hysteria  is  regularly  katathymic,  in  epilepsy  usually 
autotoxic,  while  in  schizophrenia  sometimes  more  of  the  one,  then 
again  the  other. 

Corresponding  to  the  nature  of  the  positive  affects  in  the  normal, 
the  mood  of  these  patients  is  much  more  changeable  than  in  de- 
pressed cases.  They  follow  the  different  topics  of  conversation  with 
their  affective  fluctuations,  but  generally  do  not  abandon  the  euphoric 
state.  In  a  few  cases,  however,  such  fluctuations  may  go  as  far  as 
depressions  in  which  the  patients  may  be  moved  to  tears  by  a  sad 
performance. 

Just  as  we  have  retardation  in  depression,  so  in  exaltation  we 
often  have  a  fluent  course  of  ideas  up  to  flight  of  ideas;  the  ready 
translation  of  thoughts  into  acts  is  regularly  observed.  Manic  patients 
look  younger,  the  turgor  vitalis  is  increased,  the  posture  is  the  direct 
opposite  of  that  of  depression.    The  other  physical  symptoms  are  less 


I 


GENERAL  PSYCHOPATHOLOGY  123 

marked  than  in  depression,  even  though  the  pulse  has  a  tendency  to 
be  full  and  soft. 

Exaltation,  like  depression,  may  appear  intercurrently  in  every 
mental  disease;  in  manic  states  it  forms  part  of  the  picture  and  in 
manic  depressive  insanity  it  is  a  component  of  the  disease  itself.  As  a 
chronic  state  it  occurs  in  alcoholics,  also  as  a  partial  symptom  in 
psychopathic  constitutions. 

Morbid  Irritability 

A  uniformly  overstrong  activity  of  all  affects  may  be  the  founda- 
tion of  an  abnormal  character  as  well  as  of  hysterical  and  similar 
morbid  pictures.  Furthermore,  such  an  anomaly  occurs  in  the  organic 
psychoses  and  in  epilepsy,  and  temporarily,  also,  in  simple  exhaus- 
tion where  one  may  see  all  kinds  of  "affective  crises,"  not  only  of 
the  endogenous  but  of  the  reactive  depressive  type.  However,  what 
one  understands  as  morbid  irritation  is  a  special  tendency  to  ill-temper, 
anger,  and  rage.*^  It  occurs  even  in  neurasthenics,  who  can  become 
exceedingly  angry  over  all  stronger  sense  impressions  and  every  dis- 
turbance. In  the  really  insane  we  see  it,  as  was  mentioned,  as  one 
of 'the  manifestations  of  exaltation,  then  again  it  may  accompany,  as 
a  more  independent  affective  disturbance,  all  forms  of  dementia.  This 
is,  in  part,  founded  on  the  fact  that  rage  is  the  normal  reaction  to  a 
dangerous  situation  that  one  does  not  understand;  under  such  cir- 
cumstances reflection  is  useless,  on  the  other  hand,  a  blind  effort  to 
strike  at  random  or  tear  away  without  consideration  for  the  en- 
vironment and  the  integrity  of  one's  own  body,  may  at  times  save 
one's  life. 

On  the  contrary,  in  other  irritable  characters  we  perceive  the  in- 
tellectual disturbance,  the  false  conceptions  of  the  surroundings  with 
morbid  self-reference,  as  a  result  of  the  affect  of  irritability,  and  even 
though  these  people  always  appear  somewhat  onesided  or  "narrowed" 
they  sometimes  retail!  an  intelligence  which  is,  on  the  whole,  good. 

Imbeciles  manifest  in  addition  moodiness  which  comes  from 
within,  and  easily  assumes  the  form  of  irritated  cloudiness  of  thought. 
Here  we  see  most  frequently  a  peculiar  symptom  of  rage,  that  actually 
turns  the  action  against  themselves,  which  rarely  occurs  in  other 
patients.  The  patients  tear  their  hair,  scratch  their  face  or  destroy 
other  things  so  that  they  perforce  hurt  themselves.  Often  they  only 
tear  their  clothing.  Such  damaging  of  the  environments,  including 
their  own  clothing,  are  very  common  in  schizophrenics,  at  times  it 
is  the  result  of  excitations  coming  from  within,  then  again  it  is  a 

■^The  disposition  to  anger  is  not  always  identical  with  rage. 


124  TEXTBOOK  OF  PSYCHIATRY 

reaction  to  outer  harmless  experiences.  In  severe  cases  of  schizophrenia 
outbursts  of  rage  and  anger  are  often  the  only  remaining  signs  of 
affects,  while  in  the  milder  cases  less  severe  irritability  is  the  only 
indication  of  the  disease  that  impresses  the  environment.  In  epileptics 
we  often  see  a  chronic  irritability  as  a  partial  manifestation  of  the 
general  increase  in  intensity  of  the  affects,  and  further,  as  a  passing 
state  of  depression  in  quite  the  same  way  as  in  imbeciles. 

Apathy 

Apathy  in  the  sense  that  the  affects  are  destroyed  probably  does 
not  occur  in  the  psychoses;  as  a  matter  of  fact  we  see  all  affects 
retained  in  the  brain  in  the  most  severe  organic  destructions.  Never- 
theless there  are  many  cases  of  schizophrenia  which  for  years  show 
no  impulses  or  affects.  In  senile  patients  who  no  longer  show  a 
proper  understanding  of  this  world  we  sometimes  see  a  total  lack  of 
interest  in  everything  that  occurs  about  them,  which  is  much  less 
frequently  the  case  in  matters  of  personal  contact  with  them. 
Melancholies,  who  are  so  immersed  in  their  misery  that  everything 
else  appears  insignificant,  are  sometimes  mistaken  as  apathetic. 
Many  of  them  maintain  that  they  no  longer  have  feelings,  that  they 
are  apathetic,  because  in  the  face  of  the  great  agony  entailed  in  the 
disease,  they  can  no  longer  discern  any  feelings  for  their  own  family. 
In  contrast  to  neurasthenic  irritability  there  is  a  neurasthenic  in- 
difference which  no  longer  bothers  with  anything.  Even  more  fre- 
quently do  hysterics  shut  off  their  affects  altogether  for  a  shorter 
time,  so  that  they  appear  apathetic.  The  chronic  and  totally  apathetic 
"psychasthenics"  whom  the  French  describe,  we  undoubtedly  would 
include  with  the  schizophrenics. 

Variable  Duration  of  the  Affects 

An  abnormally  long  duration  of  the  affects  occurs  in  many  people 
not  mentally  deranged,  who  cannot  get  over  an  ill  humor  and  must 
always  carry  with  them,  for  instance,  a  hatred.  In  epilepsy,  the 
affects,  once  aroused,  also  persist  an  abnormally  long  time,  even 
when  other  experiences  intervene.  A  slight  annoyance  may  also 
excite  a  congenital  feeble-minded  person  for  days.  Such  patients 
possess   too   slight  an  affective  distractability. 

More  important  and  better  known  is  the  excessive  lability  of  the 
affects,  their  abnormally  brief  duration  and  their  increased  affec- 
tive distractability.  Children  are  normally  labile;  they  are  rightly 
compared  with  seniles;  except  that  all  organic  cases  should  in  this 
respect  be  mentioned  together.    The  affects  are  very  easily  aroused 


GENERAL  PSYCHOPATHOLOGY  125 

in  them,  but  have  a  short  duration;  they  are  especially  capable  of 
being  too  easily  diverted.  Lability  of  the  affects  is  very  common  also 
in  the  intervals  of  more  advanced  manic-depressive  insanity.  Im- 
beciles, too,  may  suffer  from  the  same  defect. 

Emotional  Incontinence 

Most  patients  with  too  great  a  lability  of  feelings  display  less 
control  than  the  normal.  They  must  give  in  to  every  affect,  whether 
they  express  it  or  act  in  accordance  with  it.  Yet  lability  and  in- 
continence do  not  always  run  parallel.  There  are  people  without 
noticeable  lability  who  cannot  control  their  feelings.  One  of  our 
imbeciles,  who  was  none  the  less  a  pretty  good  workingman,  could 
not,  to  his  sorrow,  play  cards,  because  a  smiling  or  a  sad  countenance 
always  betrayed  to  the  other  players  whether  he  held  good  or  bad 
cards  so  that  they  could  act  accordingly.  As  far  as  action  is  con- 
cerned one  can  say  that  a  real  control  of  pathological  affects  is  not 
common  in  the  different  mental  diseases.  When  an  affect  is  present, 
the  patient  usually  acts  accordingly.  The  best  dissimulators  are 
melancholies,  and  they  resort  to  it  especially  for  the  purpose  of  getting 
an  opportunity  to  commit  suicide. 

Affective  Ambivalence 

Even  the  normal  individual  feels,  as  it  were,  two  souls  in  his 
breast,  he  fears  an  event  and  wishes  it  to  come,  as  in  the  case 
of  an  operation,  or  the  acceptance  of  a  new  position.  Such  a  double 
feeling  tone  exists  most  frequently  and  is  particularly  drastic  when 
it  concerns  persons,  whom  one  hates  or  fears  and  at  the  same  time 
loves.  This  is  especially  the  case  when  sex  is  involved  which  in 
itself  contains  a  powerful  positive  and  almost  equally  powerful  neg- 
ative factor;  the  latter  conditions  among  other  things,  the  feeling 
of  shame  and  all  sexual  inhibitions  as  well  as  the  negative  valuation 
of  sexual  activity  as  sin,  and  the  evaluation  of  chastity  as  a  cardinal 
virtue.*^ 

But  such  ambivalent  feeling  tones  are  the  exception  with  the  normal 
person.  On  the  whole  he  makes  a  decision  from  the  contradictory 
values;  he  loves  less  because  of  accompanying  bad  qualities,  and 
hates  less  because  of  accompanying  good  qualities.  But  the  abnormal 
person  often  cannot  bring  together  these  two  tendencies;  the  hate 
and  love  manifest  themselves  side  by  side  without  the  two  affects 
weakening  or  even  influencing  each  other  in  any  way.     He  wishes 

*"  Bleuler,  Der  Sexualwiderstand,  Jahrbuch  f.  Psychoanalytische  Forschungen, 
Bd.  V.  1913. 


126  TEXTBOOK  OF  PSYCHIATRY 

his  wife's  death  and  when  hallucinations  picture  it  for  him,  he  is 
desperate,  but  even  then,  besides  crying  he  can  at  the  same  time 
laugh  over  it. 

It  is  chiefly  ambivalent  complexes  that  influence  pathology  and 
many  expressions  of  the  normal  psyche,  such  as  dreams,  poetry,  etc. 
In  schizophrenia  they  come  to  light  quite  openly.  There  we  often 
see  directly  the  ambivalent  feeling  tones,  while  in  the  neuroses  they 
are  concealed  behind  a  large  part  of  the  symptoms. 

Congenital  Deficiency  and  Perversions  of  Particular  Affective 

Groups 

Congenital  deficiency  is  almost  always  described  as  a  defect  of 
the  ethical  feelings;  there  is,  besides,  though  very  seldom,  a  defect 
of  the  sexuality  with  all  its  affects. 

False  affective  accentuations  in  the  sense  of  perversions,  in  which 
the  instinctive  side  stands  in  the  foreground  (sex  impulse,  hunger 
impulse)  are  described  in  the  chapter  on  impulses.*^ 

Exaggerations  and  Onesidedness  of  the  Affective  Causes, 
Morbid  Reactions 

These  disturbances  are  of  fundamental  importance  for  the 
neuroses,  for  the  understanding  and  treatment  of  abnormal  characters, 
and  for  pedagogics,  but  of  lesser  importance  for  special  psychiatry, 
hence  we  shall  give  here  only  a  few  suggestions. 

Strong  affects  may  lead  to  disturbances  of  consciousness  in  psycho- 
pathic persons.  The  blind  rage  of  prisoners  (prison  outbreak)  and 
oligophrenics,  which  may  last  from  a  few  minutes  to  many  hours, 
is  well  known.  It  is  often  followed  by  amnesia.  Exaggerated  physical 
symptoms  such  as  fainting,  or  vomiting,  may  accompany  the  attack 
or  represent  it  alone. 

The  characteristic  factor  may  here  show  itself  in  the  force  of  the 
momentary  affect  or  in  a  lack  of  inhibitions,  the  latter  occurs  in 
definite  dispositions  such  as  manic  depressions,  alcoholic  effects,  etc. 
When  the  effect  is  more  chronic  in  psychopathic  individuals  delusions 
are  easily  formed,  which  disappear  with  a  change  of  the  situation. 
A  part  of  the  prison  psychoses  *^  belong  here. 

Instead  of  acting  forcibly,  the  affect  can  inhibit  itself  and  then 
leads  to  stupor  wherein  thoughts  and  outer  reactions  are  shut  off; 

*'  For  Affective  Disturbances  of  the  Individual  Morbid  Groups  see  Symp- 
tomatology of  the  Diseases  in  special  part. 

^'Cf.  especially  Birnbaum:  Psychosen  mit  Wahnbildung  und  Wahnhaften 
Einbildungen  bei  Degenerativen.     Marhold,  Halle  a.  S.  1908. 


GENERAL  PSYCHOPATHOLOGY  127 

or  the  affect  alone  is  suppressed,  so  that  a  particularly  terrifying 
experience  is  calmly  considered  and  observed  but  no  affect  is  felt, 
as  in  the  cases  of  Livingstone  v^^hen  he  was  attacked  by  a  lion  and 
Balzy's  behavior  during  an  earthquake.  In  a  lesser  degree  we 
observe  a  kind  of  indifference  in  children  and  psychopaths  (belle 
indifference  des  hysteriques).  The  mental  stream  may  become  con- 
fused as  in  making  a  speech. 

Not  quite  identical  with  the  affective  stupor  is  the  embarrass- 
ment which  is  to  be  conceived  in  the  broadest  sense.  It  is  often 
only  a  question  of  a  different  attitude,  as  where  it  is  impossible  to 
do  some'thing  consciously  which  can  otherwise  be  done  well  more  or 
lesg  automatically,  as  opening  certain  locks  and  similar  acts.  If  an 
affect  is  added,  the  effect  is  naturally  still  stronger.  What  is  known 
in  one  situation  is  not  at  one's  disposal  in  the  other  (Examination 
stupor  and  stairway  wit).  If  a  special  effort  is  made  to  accomplish 
something,  or  when  one  fears  lest  he  make  a  failure  of  it,  he  is  then 
sure  not  to  succeed,  a  mechanism  seen  in  stuttering,  bladder  control, 
impotence,  and  erythrophobia.  As  a  matter  of  fact  every  act  which 
is  more  or  less  automatic,  be  it  psychic  or  physical,  is  disturbed 
through  the  interference  of  the  conscious  will.  As  examples  we  may 
mention  the  common  chronic  constipation  as  a  result  of  a  psychic 
habit  to  drugs  or  occupation  with  the  bowels,  the  complaints  of 
menstruation,  and  the  difficulties  of  childbirth. 

Stuporous  states  can  become  chronic  in  connection  with  definite 
situations  or  a  definite  morbid  symptom,  also  in  the  face  of  a  certain 
teacher  or  subject  where  something  awkward  had  occurred.  And 
yet  a  pupil  who  reacts  in  this  manner  may  appear  normal.  The 
most  stupid  way  to  correct  it  is  to  bully  the  patient.  On  the  con- 
trary, one  must  make  the  effort  to  remove  the  affect  by  kindly  ignor- 
ing it,  or  in  the  more  intelligent  patients  one  can  establish  a  different 
mental  attitude  through  enlightenment.  Inner  complexes  also  act 
in  the  same  way.  The  onanism  complex,  and  not  the  onanism,  con- 
tinually prevents  the  patient  from  concentrating  on  other  things,  so 
that  he  gives  the  impression  of  having  a  poor  memory.  Depressive 
and  exalted  moods  emanate  from  such  complexes.  Thus  a  man  is 
more  homosexually  than  heterosexuaJly  predisposed  and  becomes 
dissatisfied  with  his  married  life,  but  he  cannot  grasp  the  situation 
in  view  of  his  love  for  his  wife  with  whom  he  apparently  lives  happily. 
He  finally  becomes  depressed  but  improves  as  soon  as  everything  be- 
comes clear  to  him  and  he  adjusts  himself  to  it. 

Continuous  false  attitudes  result  particularly  from  an  injury  to 
one's  personality  through  acts  which  are  considered  "unjust."    Y'oung 


128  TEXTBOOK  OF  PSYCHIATRY 

people,  and  even  children  in  the  first  years  can  in  this  way  acquire 
and  forever  continue  a  false  attitude  towards  life. 

Thus  develops  functionally  an  entirely  different  type  of  character, 
usually  unsocial,  who  can  he  differentiated  from  the  congenital  type 
only  through  close  observation,  hut  who  can  he  changed  hack.  Of 
diagnostic  significance  is  the  existence  in  many  cases  of  moral 
feelings  from  which  one  must  naturally  exclude  the  mere  "weaknesses 
of  will"  resulting  from  flighty  affects.  Parents  and  teachers  do 
not  understand  certain  reactions  of  the  child  and  punish  him  for  them. 
The  child  conceives  that  as  an  injustice,  and  assumes  a  rebellious 
attitude.  Everything  is  then  viewed  under  the  guise  of  this  complex 
and  a  moral  attitude  is  formed  which  particidarly  fits  this  purpose 
and  runs  something  like  the  following:  ''My  father  has  been  unfair 
to  me,  he  is  to  blame  for  everything.  It  is  only  just  that  I  disgrace 
him  through  stealing."  Such  reflections  assume  so  exclusive  an  im- 
portance that  a  regard  for  one's  own  welfare  entirely  disappears: 
"It  serves  you  right  that  my  hands  are  frost  bitten,  it  is  just 
what  you  wanted"  becomes  a  maxim  and  cannot  be  corrected  by 
ordinary  reflection,  simply  because  all  the  associations  become 
only  half  conscious,  if  at  all.  It  is  only  by  correct  treatment, 
especially  by  analysis  that  such  a  stubborn  individual  can  be 
saved  from  lasting  criminality.  A  young  woman  merges  into  an 
"expectation  neurosis"  to  spite  her  husband,  who  treated  her  dis- 
gustingly, and  throughout  her  whole  life  cannot  extricate  herself 
from  the  disease  even  after  her  husband  died.  To  be  sure  there 
were  also  other  important  factors  which  determined  the  origin 
and  particularly  the  special  kind  of  the  disease.  Little  children 
often  cannot  emerge  from  their  spiteful  attitude  although  they  are 
seemingly  willing — and  the  same  is  true  of  argumentative  adults; 
that  accounts  for  the  favorable  results  that  are  often  brought  about 
by  outsiders. 

Similar  attitudes,  though  of  lesser  degree,  result  in  young  people 
who  possess  special  talents  in  manual  skill,  art,  or  in  any  other 
sphere,  but  who  are  forced  to  learn  to  occupy  themselves  with  some- 
thing else.  They  are  dissatisfied  with  themselves  and  the  world, 
they  are  incapable  of  accomplishing  things,  they  show  a  tendency 
for  all  kinds  of  neuroses,  and  are  forced  to  assume  a  dereistic  or 
negativistic  attitude  to  the  world.  The  same  is  the  case  in  people 
who  wish  to  go  too  high.  Many  dissatisfactions,  neuroses  and  some 
psychoses  (paranoias)  result  from  a  disproportion  between  aim  and 
ability.  Bumke  tells  what  is  quite  characteristic,  namely,  that  a 
striking  number  of  students  who  appeal  tq  him  for  treatment  be- 


GENERAL  PSYCHOPATHOLOGY  129 

cause  they  are  no  longer  capable  of  mental  work  think  seriously  of 
qualifying  for  academic  positions. 

An  unsuccessful  separation  from  the  parents  has  similar  results. 

Also  a  former  disagreeable  experience  can  result  in  false  attitudes 
or  a  tendency  to  certain  neurotic  diseases. 

Affects  and  impulses  that  cannot  be  gratified  often  find  spon- 
taneously a  harmless  discharge,  or  under  conscious  guidance  the 
affects  and  impulses  may  be  utilized  for  similar  activities.  Thus 
sexual  love  and  the  childish  impulse  associate  themselves  with  ordi- 
nary love  for  mankind  and  occupy  themselves  with  charity  and 
nursing  the  sick  (Freud's  sublimation).  Sometimes  they  change  into 
childish  exaggerations  as  seen  in  the  love  evinced  by  old  maids  for 
cats  and  pups;  frequently,  however,  this  does  not  gratify  the  original 
impulse,  especially  when  the  latter  is  repressed.  The  sublimation 
then  manifests  itself  only  in  repeated  flare-ups  of  straw  fire  which 
can  never  cook  the  soup. 

Under  other  circumstances  the  affects  become  stirred  up  in  the 
unconscious.  Every  new  similar  experience  increases  the  tension; 
thus  there  is  on  the  one  hand,  an  explosion-readiness  to  certain  ex- 
periences, and  on  the  other  hand,  an  unconscious  affective  search  for 
such  processes.  A  child  that  has  once  experienced  great  anxiety 
without  understanding  it  correctly,  or  when  the  experience  becomes 
repressed  by  the  anxiety,  becomes  more  and  more  timid;  it  becomes 
sensitized  to  anxious  experiences  and  peculiarly  enough  it  repeatedly 
meets  with  accidents  which  stimulate  anxiety.  Later  such  a  child 
becomes  neurotic. 

The  hunger  for  excitement  of  some  people  comes  about  in  this 
manner.  There  are  people  who  must  always  be  doing  something, 
it  matters  little  whether  the  situation  is  of  a  pleasurable  or  painful 
nature.  Sometimes  a  decided  preference  is  shown  for  the  latter, 
they  experience  "ecstatic  pain,"  martyrlike  pleasure,  and  forever  con- 
sider themselves  unfairly  treated.  Every  occasion  is  skilfully  elabo- 
rated into  a  ''scene;"  and  their  own  misfortunes  are  not  only  relished 
but  decidedly  more  or  less  instigated  and  brought  to  a  point.  (The 
normal  prototype  is  seen  in  the  enjoyment  of  a  tragedy.)  The 
elaboration  is  often  an  inner  one;  thus  any  kind  of  experiences  are 
misinterpreted  in  the  sense  of  martyrdom  and  by  some  patients  also 
in  the  sense  of  self-aggrandizement.  Many  of  these  patients  seem 
abnormal  only  under  definite  conditions  or  to  certain  persons,  other- 
wise their  reactions  are  normal. 

.Complex  ideas  are  sometimes  mightier  than  the  repressing  forces. 
One  is  then  pursued  by  a  memory  throughout  life;  any  similar  ex- 


130  TEXTBOOK  OF  PSYCHIATRY 

periences  cause  them  to  reappear  with  their  entire  affective  load,  or 
they  are  even  more  or  less  constantly  present  in  consciousness,  domi- 
nating the  mood  and  the  inner  and  outer  reactions  (the  dysamnesia 
of  Cecile  Vogt). 

Partly  congenital  and  partly  determined  by  complexes  is  the  ex- 
aggerated need  for  change,  or  the  impossibility  to  tolerate  long  any 
kind  of  situation.  No  matter  where  the  person  is  he  is  either 
"homesick"  or  in  some  "mix-up."  After  a  little  while  every  occupa- 
tion has  something  wrong  about  it.  On  the  one  side  the  normal  need 
for  change  is  exaggerated,  on  the  other  there  is  a  lack  of  love  for 
the  customary. 

A  familiar  feeling  is  the  impossibility  of  getting  out  of  one's  shell, 
or  the  inability  to  express  oneself,  observed  in  many  persons  who  have 
to  endure  much  injustice  without  being  able  to  defend  themselves. 
They  conceal  their  feelings,  are  inclined  to  secretiveness,  and  easily 
become  untruthful  despite  their  good  character. 

As  everywhere  else  it  is  especially  ambivalent  complexes  which 
become  pathogenic  in  this  manner,  also  situations  which  render 
prominent  the  negative  side  of  a  suggestion  or  of  a  tendency.  If 
one  offers  sweets  to  a  little  child  and  indicates  by  tone  of  voice 
or  in  any  other  way  that  it  is  expected  to  react  to  it  with  pleas- 
ure and  special  thanks,  he  can  be  quite  certain  that  the  child  will 
not  accept  it.  It  is  really  only  a  matter  of  accident  whether  the 
machine  moves  backward  or  forward.  He  who  reacts  to  a  complex 
with  stealing  is  often  hardly  worse  than  another  who  responds  to 
the  situation  with  self-sacrifice. 

The  difficulty  lies  less  frequently  in  the  events  than  in  the 
incompatibility  of  the  characters  living  together.  Let  us  say  that 
the  husband  is  a  very  easy  going  person  while  the  wife  is  active  and 
hungry  for  excitement.  No  matter  how  slight  the  difficulty  is,  she 
finds  the  need  for  making  a  scene;  the  more  extreme  her  expressions, 
the  less  the  husband  is  able  to  get  out  of  himself,  which  thus  only 
enhances  her  affect.  This  continues  until  the  vicious  circle  is  broken 
by  some  small  or  big  catastrophe. 

Both  under  occasional  as  well  as  under  repeated  or  chronic  in- 
fluences there  result  false  attitudes  which  not  only  impede  the  ad- 
justment but  under  certain  discomforts  make  it  more  and  more 
sensitive.  A  stimulus  accepted  as  a  matter  of  course  causes  no 
disturbance.  Thus  if  we  should  be  disturbed  at  home  by  a  person 
making  a  big  noise  and  shaking  the  chair  we  are  sitting  in,  any 
intellectual  work  would  be  impossible,  but  in  similar  conditions  of 
noise  and  motion  in  a  moving  train  we  might  be  able  to  concentrate 


GENERAL  PSYCHOPATHOLOOY  131 

on  any  intellectual  work  even  better  than  at  our  writinj^  table.  The 
baby  who  cannot  yet  think  that  people  should  be  quiet  for  his  sake 
adapts  himself  to  any  noise,  the  wife  doesn't  hear  the  snoring  of  the 
husband  she  loves,  and  the  exertions  in  frames  of  sport  are  per- 
ceived as  enjoyment  and  recreation  despite  the  fact  that  it  exceeds 
by  far  the  "tiring"  resulting  from  work.  A  great  part  of  the  so- 
called  neurasthenic  symptoms  and  the  whole  "expectation  neurosis" 
are  based  on  such  attitudes.  Depending  on  the  attitude  assumed, 
one  becomes  particularly  sensitive  to  events  which  repeat  themselves 
or  particularly  insensitive,  a  fact  which  holds  true  also  for  material 
or  moral  filth. 

A  very  useful,  though,  to  be  sure,  as  little  exhaustive  as  a  sharply 
defined  classification  of  reaction  types  to  difficulties,  is  given  by 
Kretschmer.  The  hysteric  evades  the  struggle,  the  erethic  takes 
it  up  and  magnifies  it,  the  sensitive  individual  takes  refuge  in  his 
inner  self  and  builds  up  various  forms  of  delusions  and  obsessions, 
and  the  asthenic  person  sinks  into  an  inactive  depression. 

Other  details  concerning  morbid  affective  reactions  will  be  given 
later  under  "Psychopathic  Forms  of  Reactions." 

Pathology  of  Affective  Disturbances 

The  affective  anomalies  are  in  the  first  place  a  function  of  the 
disposition.  The  latter  is  acted  upon,  on  the  one  hand,  by  various 
reactions  which  can  become  distorted  into  morbid  states,  and  on 
the  other  hand,  there  are  endogenous  surface  reactions  of  which  the 
emotional  disturbances  of  manic  depressive  insanity  are  the  most 
striking  examples. 

These  disturbances  seem  to  correspond  to  physiological  (chemical) 
attitudes.  It  is  nevertheless  remarkable  that  many  manic  depres- 
sive patients  react  with  abnormal  force  to  psychic  stimuli  during 
their  healthy  interval,  which  leads  one  to  believe  that  the  attacks 
of  the  disease  may  be  put  side  by  side  with  these  psychogenic 
fluctuations.  Moreover,  a  small  portion  of  the  actual  manic  depressive 
manifestations  is  dissipated  by  psychic  reasons,  and  it  is  known 
that  there  are  similar  emotional  disturbances  which  do  not  belong 
to  this  disease  and  which  are  put  in  operation  by  psychic  factors. 
The  difficulty  is  undoubtedly  solved  in  the  following  manner:  The 
affects  like  other  psychisms  reenforce  one  another;  a  depression,  for 
example,  unites  the  depressive  associations  and  inhibits  those  of  a 
euphoric  tendency;  in  this  way  the  affect  is  strengthened  and  main- 
tained. In  the  same  manner  it  inhibits  in  the  physical  sphere,  for 
example,   respiration   and   digestion,   it   affects  the   pulse   more  un- 


132  TEXTBOOK  OF  PSYCHIATRY 

favorably,  and  lets  loose  the  inner  secretory  processes  corresponding 
to  it,  which  can  again  reenforce  the  affect.  The  disease  causing 
agent  can  attack  in  any  preferred  place  of  these  two  circular  con- 
necting causes.  Let  us  assume  that  in  the  manic  depressive  patient 
there  exists  a  special  lability  in  the  functions  of  the  endocrine  glands. 
The  fluctuations  of  the  glandular  activities  may  be  conditioned  by 
causes  existing  outside  of  them;  but,  as  probably  happens  in  the 
periodicity,  this  function  can  also  become  too  easily  exhausted  and 
then  again  functionate  too  strongly.  In  both  cases  we  have  the  usual 
manic  depressive  attack  which  is  conditioned  "from  inside  to  outside" 
— but  similarly  an  attack  results  when  the  glands  react  too  strongly 
to  an  exogenously  (psychic)  determined  depression. 

Most  of  the  emotional  disturbances  of  epileptics  and  of  some  oligo- 
phrenics are  also  conditioned  by  some  chemism.  It  is  nevertheless  a 
striking  fact  that  precisely  the  oligophrenics  with  brain  lesions  and 
particularly  patients  suffering  brain  injuries,  show  a  tendency  to 
produce  endogenous  emotional  disturbances  which  are  mostly,  though 
not  exclusively,  of  an  irritable  nature.  The  continuous  irritability 
seen  in  those  who  have  brain  lesions  is  also  anatomically  determined. 
It  is  not  absolutely  certain,  but  according  to  many  obserA^ations  it 
is  probable  that  there  are  also  periodic  emotional  disturbances  of  a 
psychogenic  nature  analogous  to  the  lasting  attitudes  mentioned  above. 
Any  kind  of  complex,  let  us  say,  dissatisfaction  with  parents,  be- 
comes half  or  completely  repressed  so  that  the  child  cannot  fully 
account  to  himself  for  his  actions.  But  the  need  for  abreaction  finds 
some  vent  through  excitements  or  emotional  disturbances  and  is 
then  followed  by  a  calm  period.  By  and  by,  however,  the  tension 
accumulates  again  only  to  express  itself  in  the  same  manner  without 
any  new  cause,  or  through  some  ordinary  occasion. 

The  lability  of  organic  patients  is  but  a  secondary  manifesta- 
tion of  the  general  cerebral  disturbance.  For  we  note  a  slight  per- 
severance of  the  psychisms  even  in  the  spheres  of  memory,  and  the 
limitation  of  the  associations  is  undoubtedly  responsible  for  the  fact 
that  only  actual  situations  are  reacted  to.  In  epilepsy,  on  the  con- 
trary, all  the  other  psychisms  run  a  slow  course;  the  getting  away 
from  an  idea  is  just  as  difficult  as  the  alteration  of  an  affect. 

The  tendency  to  depression  in  senile  patients  is  not  adequately 
explained  by  the  suggestion  that  depressions  increase  with  age  and 
especially  with  general  circulatory  disturbances.  Also  the  euphoria 
of  paresis  is  as  little  explained  as  the  rare  paretic  depressions. 

The  morbid  reactions  require  no  special  explanation,  as  they  spring 
from  normal  mechanisms,  and  act  in  an  exaggerated  and  one-sided 


GENERAL  PSYCIIOPATHOLOGY  133 

manner   only    in    conHcquenco    of   extraordinary    occasions    or    of    a 
disposition  deviating  from  the  normal. 

8.    DISTURBANCES    OF   ATTENTION 

The  pathology  of  attention  is  very  complicated  because  its  effects 
are  strongly  influenced  by  the  other  functions.  Exhaustion  and 
many  morbid  states  weaken  the  faculty  of  concentration.  The  scope 
of  attention  is  determined  by  the  amount  of  associations  that  may 
occur  at  the  same  time;  it  is  consequently  lowered  in  organic  patients. 
The  exaggerated  readiness  of  psychic  processes  in  manic  cases  weakens 
the  inhibiting  effect  of  the  effort  of  tenacity  upon  distracting  in- 
fluences. The  lack  of  tenacity  in  organic  cases  is  sometimes  irregu- 
larly over-compensated  by  torpid  retardation  of  the  psychic  processes, 
so  that  secondary  hypo-vigility  goes  hand  in  hand  with  lack  of 
tenacity.  In  twilight  states,  toxemias  and  similar  states,  where  the 
mental  trend  becomes  quite  unintelligible,  one  can  hardly  still  speak 
of  attention,  even  where  distinct  affects  are  present,  because  the  inner 
and  outer  strivings  may  become  disconnected.  The  following  remarks, 
therefore,  emphasize  only  the  most  important  facts  in  a  somewhat 
schematical  and  simpler  manner. 

Ceteris  paribiLS  attention  varies  with  the  affects.  When  the  latter 
are  labile,  or  when  the  same  interest  is  given  to  the  most  dissimilar 
ideas, — as  raising  all  ideas  upwards  in  the  manic  states,  and  lower- 
ing them  to  zero  in  cases  of  indifference  and  lack  of  comprehension, 
the  vigility  and  the  distractibility  of  attention  naturally  are  quite 
marked.  Tenacity  need  not  here  be  diminished,  because  even  with- 
out distractibility  the  subject  may  be  adhered  to;  to  be  sure,  there 
are  few  situations  in  which  outer  and  inner  distractibilities  are  absent 
for  any  length  of  time. 

If  the  affects  are  stable,  the  tenacity  also  runs  high. 

In  Schizophrenia  and  exceptional  states  of  epilepsy,  more  seldom 
in  neurasthenia  and  other  affections,  we  sometimes  find  a  strange 
mixture  of  exaggerated  and  slight  distractibility.  The  patients  react 
with  difficulty  to  questions  and  other  stimuli,  but  they  react  to  many 
accidental  sensory  impressions  such  as  the  striking  of  the  clock,  the 
entrance  of  a  person,  a  word  not  addressed  to  them,  or  to  any  object 
which  happens  to  strike  their  eyes.  But  the  epileptics  and  some  schizo- 
phrenics will  then  regularly  return  to  their  former  themes. 

The  concentration  depends  mainly  upon  the  strength  of  the  af- 
fectivity,  yet  in  labile  affects  it  is  usually  insufficient. 

Whether  tenacity  is  good  or  not  in  weak  affects  and  correspond- 


134  TEXTBOOK  OF  PSYCHIATRY 

ing  slight  concentration  depends  upon  the  accompanying  circum- 
stances. An  apathetic  schizophrenic  can  concentrate  for  half  a 
day  all  his  small  strength  on  a  little  thread  which  he  holds  in  his 
hand.  On  the  other  hand,  he  may  be  diverted  by  every  trifle,  be- 
cause no  interest  to  speak  of  restrains  him.  Hypotenacity,  combined 
with  hypovigility,  is  a  usual  manifestation  where  affects  and  in- 
telligence are  low,  as  in  clouded  states,  apathetic  imbecility,  and 
other  cases. 

Hypotenacity,  without  real  hypovigility,  is  found  in  Aprosexia; 
there  is  an  inability  to  concentrate  one's  thoughts  in  reading,  for 
instance,  even  for  a  short  time.  This  symptom,  which  is  not  found 
very  frequently,  occurs  in  neurasthenia,  and  in  impeded  nasal  breath- 
ing as  a  result  of  adenoids. 

Vigility  and  tenacity  are  lowered  in  Chorea  Minor,  also  in  some 
cases  of  torpid  imbecility,  although  here  the  genetic  factors  are 
quite  different. 

A  rapid  "exhaustion"  of  attention  can  be  observed  in  many  organic 
cases,  especially  in  those  with  coarse  brain  lesions,  also  sometimes 
in  schizophrenics  during  the  acute  stages.  On  the  other  hand,  it  often 
takes  organic  patients  a  longer  time  to  concentrate  their  attention 
on  the  very  subject  desired.  It  is  for  this  reason  that  perception 
experiments  with  such  cases  turn  out  very  badly  at  first,  but  after 
some  time  the  results  are  betterj  until  the  exhaustion  reappears  and 
the  patients  again  do  badly. 

The  scope  of  attention  is  diminished  in  organic  cases  and  in  oligo- 
phrenics because  of  a  restriction  of  associations,  and  in  melancholic 
and  paranoid  patients  as  a  result  of  one-sided  interest,  and  in  epileptics 
as  a  result  of  both  factors.  In  all  forms  of  paranoia  or  paranoid 
states  we  also  have  as  an  important  symptom  the  systematized 
vigility,  the  morbid  association  readiness  for  those  events  which  might 
be  connected  with  their  delusions.^^ 

In  organic  patients,  the  habitual  attention  is  earlier  and  more 
strongly  disturbed  than  the  maximal  attention.  The  patients,  for 
instance,  may  seem  completely  normal  as  to  attention  during  a 
clinical  demonstration,  but  at  the  same  time  they  are  disoriented 
in  the  ward  where  they  have  been  for  weeks,  they  cannot  locate 
their  bedroom  or  their  bed,  because  they  do  not  register  anything 
that  happens  about,  and  even  to  them,  if  they  have  no  special  reason 
for  being  attentive.  And  what  is  more,  the  memory  and  the  compre- 
hensive functions  of  orientation  may  still  be  adequate  in  these  cases, 
so  that  the  mistake  can  safely  be  ascribed  to  the  faculty  of  attention. 

**  Cf.  Delusions  of  reference,  p.  94. 


GENERAL  PSYCHOPATHOLOGY  135 

The  patients  observe,  as  it  were,  nothing,  unless  attention  is  forced 
upon  them  through  some  circumstance,  then  they  behave,  however,  in 
quite  a  normal  way.  This  teaches  us  that  intensity,  at  least,  of  maxi- 
mal attention  can  be  good,  in  spite  of  the  markedly  diminished  field 
of  associations. 

Tenacity  of  attention  in  organic  cases  is  mostly  lowered;  the 
pa>tients  cannot  continuously  occupy  themselves  with  one  thing;  they 
digress  and  tire  simultaneously,  very  quickly.  But  the  same  patients 
find  it  also  difficult  to  transfer  their  thoughts  to  another  subject 
offered  to  them.  They  evince  at  the  same  time  hypotenacity  and 
(secondary)  hypovigility  of  attention.  In  the  manic  stages  of 
paresis,  hypovigility  may  be  hidden  by  the  distractibility  of  the 
flight  of  ideas,  yet  it  can  usually  be  demonstrated  through  examina- 
tion, for  the  patients  after  discussing  their  personal  affairs  cannot 
quickly  answer  a  question  about  their  school-knowledge,  nor  are  they 
even  able  to  understand  it  correctly,  and  this  happens  even  where  the 
psychic  processes  in  general  function  very  quickly.  The  excited  states 
of  presbyophrenia  can  also  cause  an  over-compensation  of  hypo- 
vigility. 

In  the  schizophrenics,  the  relation  of  active  and  passive  atten- 
tion is  the  reverse  to  that  of  the  organics.  They  register  excellently 
what  is  going  on  around  them,  even  if  they  do  not  pay  any  special 
attention  to  it;  but  if  they  should  have  to  concentrate  their  atten- 
tion, they  could  not  succeed,  sometimes  they  are  hindered  by  block- 
ings and  at  the  same  time  they  often  cannot  hold  a  subject. 

In  some  cases  of  schizophrenias,  especially  in  crowding  of  thought, 
in  fatigue,  in  hallucinations  and  delusions,  in  phobias  and  other  obses- 
sions, and  in  the  pathological  readiness  for  association,  the  direction 
of  attention  is  obsessive. 

In  ordinary  fatigue,  the  power  of  concentration  and  tenacity  are 
usually  very  much  diminished,  whereas  the  distractibility  seems  to 
be  enhanced  in  varying  ways. 

There  is  a  tendency  to  explain  many  other  manifestations  on  the 
basis  of  disturbances  of  attention,  and  as  a  deficiency  of  attention 
may  be  responsible  for  all  sorts  of  stupidities,  such  deductions 
can  be  easily  constructed,  but  just  for  these  reasons  most  of  these 
explanations  have  no  scientific  value. 

9.    MORBID  SUGGESTIBILITY 

A  total  lack  of  suggestibility  does  not  perhaps  occur  except  in  such 
patients  who  evince  an  utter  lack  of  comprehension  and  who  no  longer 


136  TEXTBOOK  OF  PSYCHIATRY 

react  to  stimuli.  A  marked  diminution  of  suggestibility  we  observe 
occasionally  in  imbeciles,  who  are  then  naturally  incapable  of  any 
training.  Schizophrenic  patients  are  often  little  or  not  at  all  re- 
sponsive to  direct  suggestions,  but  in  most  cases  they  still  react  very 
slightly  to  the  general  attitude  of  their  environment.  Wherever 
individual  groups  of  affects  are  lacking,  suggestion  in  the  corre- 
sponding sense  is  naturally  impossible.  Moral  idiots  cannot  be  in- 
fluenced in  a  moral  sense,  or  irreligious  people  in  a  religious  sense. 
Paretic  patients  in  a  manic  state  who  look  at  the  good  side  of  every- 
thing and  accentuate  it  with  a  feeling  of  happiness  can  hardly  be 
brought  to  accept  a  sad  situation. 

The  exaggerations  of  suggestibility  are  more  important.  We  can 
produce  it  experimentally  in  a  state  of  hypnosis.  Many  people  are 
by  nature  as  susceptible  to  all  influences  as  a  soft  piece  of  dough. 
Fatigue  and  emotional  experiences  show  a  temporary  disposition  for 
suggestibility.  Patients  in  manic  states  or  those  suffering  from  organic 
disturbances  as  well  as  alcoholics  are  easily  influenced  by  suggestions. 

Just  as  suggestibility  is  enhanced  by  the  lability  or  resonance  of 
the  affects  so  it  is  heightened  also  through  any  decrease  in  the 
critical  faculty  which  normally  counteracts  suggestions.  All  things 
being  equal,  the  more  thoughtless  a  person,  the  more  suggestible 
he  is. 

Morbid  suggestibility  may  lead  to  induced  insanity,  also  to  psychic 
and  neurotic  epidemics,  to  participations  in  crimes,  and  similar  acts. 

Hand  in  hand  with  positive  suggestibility,  there  is  in  most  cases 
also  an  increase  in  the  negative  suggestibility.  Like  children,  senile 
patients  are  now  wilful,  and  now  open  to  the  most  stupid  prompt- 
ings. Paranoid  patients  allow  themselves  to  be  easily  fooled  by 
people  who  have  their  confidence,  whereas  they  are  absolutely  inacces- 
sible to  other  persons.  In  schizophrenic  cases  we  often  find  com- 
mand automatism  and  echopraxia,  that  is,  high  degrees  of  suggestibility 
combined  with  a  pronounced  negativism. 

The  so-called  auto-suggestion  is  an  important  source  of  morbid 
states.  No  neuroses  are  possible  without  its  cooperation  ("Imaginary" 
diseases).  Thus  a  girl  in  a  street  car  sees  an  eczematous  eruption 
on  the  hand  of  another  passenger  and  becomes  very  excited  because 
it  unconsciously  touched  her  "complex"  referring  to  her  paretic  or 
luetic  father;  she  then  develops  an  eczema-like  eruption  in  the  same 
place  as  the  passenger.^"  A  traumatic  patient  fears  that  he  can  no 
longer  support  his  family  and  hopes  to  assure  his  existence  through 

^°  Friedman  u.  Kohnstamm,  Zur  Pathogenese  u.  Psychotherapie  bei  Basedow- 
scher  Krankheit,  Zeitschrift  f.  d.  ges.  Neur.  u.  Psych.  Or.  23,  1914. 


GENERAL  PSYCHOPATHOLOGY  137 

a  pension.  He  observes  himself  anxiously  and  by  this  very  means 
creates  the  necessary  morbid  symptoms.  A  girl  fears  lest  her  men- 
strual period  fail  to  appear,  and  thus  causes  £i  temporary  amenorrlifjea. 
To  be  sure,  auto-suggestion  may  have  the  opposite  favorable  effect 
which  is  curative  in  nature.  These  examples  show  that  positive  and 
negative  suggestions  are  really  not  true  opposites,  and  that  both 
together  are  nothing  but  emotional  effects. 

10.    DISTURBANCES  OF  PERSONALITY 

Every  mental  disorder  changes  the  personality  in  some  sense  if 
not  altogether.  The  manic  patients  become  reckless  and  actively 
exaggerated,  the  paranoid  and  in  most  cases  also  the  paranoiac  pa- 
tients lose  their  general  interests  in  life  and  live  only  in  their  de- 
lusions, the  epileptic  concentrates  on  his  physical  well-being  and  his 
petty  affairs,  the  intelligent  person  becomes  stupid  and  thoughtless 
as  a  result  of  a  dementing  process,  and  so  on. 

The  inner  disturbances  of  personality  are  not  as  comprehensible. 
Thus  an  ordinary  citizen  imagines  himself  an  emperor.  "What  he 
knows  of  the  Emperor,  he  feels  as  part  of  his  person:  appersonation. 
Even  hypochondriacal  ideas  can  be  acquired  in  this  way;  thus,  the 
medical  student  in  his  first  term  of  clinical  experience,  hearing  a  vi\-id 
description  of  some  disease  of  the  heart  and  seeing  it  demonstrated  in 
one  or  several  patients,  becomes  so  deeply  impressed  that  under  cer- 
tain conditions  he  feels  that  he  has  the  same  heart  trouble  (Morbus 
Medicorum). 

Less  frequently  the  personality  loses  some  of  its  component  parts. 
It  naturally  happens  that  certain  events  of  one's  life  are  forgotten; 
this  is  especially  true  in  schizophrenic  patients  who  forget  a  part 
of  their  disagreeable  experiences,  and  often  deny  bona  fide  actions, 
the  commitment  of  which  they  later  regret.  This  does  not,  however, 
concern  things  that  belong  to  the  essence  of  the  personality.  On 
the  other  hand,  the  most  important  components  are  often  replaced  by 
others;  thus  John  Smith  becomes  President  Harding,  or  Christ  (see 
below) . 

A  special  type  of  disturbance  of  personality  is  the  alternating 
personality,  also  known  as  dual  consciousness.  Let  us  consider  a 
hysterical  woman  who  until  now  has  lived  a  mediocre  existence.  For 
some  known  or  unknown  reason  she  falls  into  a  hysterical  sleep, 
and  on  awakening  she  has  forgotten  her  entire  previous  existence; 
she  does  not  know  who  she  is,  where  she  has  lived  until  now,  and 
who  the  persons  are  whom  she  sees  around  her.     Notwithstanding 


138  TEXTBOOK  OF  PSYCHIATRY 

this  change,  the  ordinary  faculties  of  walking,  speaking,  eating,  the 
use  of  clothes  and  other  things  are  usually  transferred  to  the  new  state 
("etat  second").  Whatever  the  patient  needs  for  her  intercourse  with 
other  people  she  learns  very  quickly.  Her  character,  too,  undergoes 
a  change;  formerly  a  serious-minded  girl,  she  now  becomes  frivolous 
and  pleasure-seeking.  After  some  time,  she  again  merges  into  a  state 
of  sleep,  and  on  awakening  the  patient  is  back  in  her  first  state. 
She  has  no  realization  of  the  intervening  time;  all  that  she  remembers 
is  that  she  went  to  sleep,  and  has  now  awakened  as  usual.  Such 
changed  states  may  appear  alternately  for  years.  While  in  the  first 
state  the  patient  only  remembers  the  former  first  states  and  when 
in  the  second  she  always  recalls  only  those  of  the  second  series. 
More  frequently,  however,  it  seems  that  in  the  second  state  the 
patient  can  recall  the  first  (normal)  series,  but  while  in  the  first 
state  she  cannot  recall  the  second  (morbid)  series.  It  may  also  hap- 
pen that  eventually  the  second  state  will  become  permanent,  and  this 
way  cause  a  transformation  of  the  personality.  In  quite  rare  cases 
there  may  be  an  alternation  of  many  such  states,  each  with  its  very 
definite  character  and  special  memory  group  (personality) ;  as  many 
as  twelve  have  been  observed.  As  a  matter  of  fact,  cases  of  pure 
dual  personalities  are  very  rare.  Yet  their  theoretical  significance 
is  very  great,  for  they  show  what  marked  changes  can  be  brought 
about  by  a  systematic  elimination  or  intercalation  of  association  paths. 
It  is  not  alone  in  hysteria  that  one  finds  an  arrangement  of  differ- 
ent personalities  one  succeeding  the  other;  through  similar  mechanisms 
schizophrenia  produces  different  personalities  existing  side  by  side. 
As  a  matter  of  fact,  there  is  no  need  of  delving  into  those  rare  though 
most  demonstrable  hysterical  cases;  we  can  produce  the  very  same 
phenomena,  experimentally,  through  hypnotic  suggestion,  and  we 
also  know  that  in  the  ordinary  hysterical  twilight  states  the  memory 
of  former  attacks,  concerning  which  the  patient  shows  an  amnesia 
in  her  normal  state,  can  be  retained  or  can  be  aroused  by  suggestion. 
The  splitting  off  of  parts  of  a  personality  in  transitivism  pro- 
ceeds in  a  different  manner;  here  the  patient's  own  experiences  become 
detached  from  him,  and  are  ascribed  to  another  person.  A  patient; 
for  example,  sees  a  terrifying  image  and  screams  aloud;  but  he 
then  imagines  that  the  apparition  did  the  screaming.  A  woman  has 
an  operation  on  her  toe,  during  the  long  drawn  out  delirium  of  the 
narcosis  she  continually  asks  the  nurse  to  look  after  her  bed-neighbor, 
because  the  latter  is  having  bad  pains  in  her  toe.  A  person  dreams 
during  the  night  before  he  has  diarrhoea  that  pamphlets  which  he 
has  to  send  out  suffer  from  diarrhoea.    It  is  quite  common  to  displace 


GENERAL  PSYCHOPATHOLOGY  139 

feeling  which  we  have  ourselves  in  our  dreams  to  other  persons. 
Transitivism  is  an  almost  common  occurrence  in  schizophrenia;  the 
patients  are  convinced  that  the  voices  which  they  hear  are  also  heard 
by  others  in  the  same  way;  they  frequently  ascribe  their  own 
actions  to  others;  thus,  if  they  read  something,  it  is  really  done  by 
others;  their  thoughts  are  thought  by  others,  and  so  on. 

A  strange  disturbance  of  personality  is  de-personalization,  in  which 
the  patients  have  lost  the  definite  idea  of  their  ego.  They  seem 
quite  different  to  themselves,  and  feel  that  they  must  look  in  the 
mirror  to  see  if  they  are  still  themselves,  and  even  then  their  own 
images  appear  strange.  This  disturbance  manifests  itself  especially 
through  the  fact  that  the  patients  do  not  feel  their  own  will  power 
and  strivings,  they  feel  like  automatons;  sometimes  they  are  indiffer- 
ent to  it,  but  in  most  cases  they  perceive  this  state  as  extremely  un- 
pleasant. This  syndrome  appears  in  schizophrenia,  perhaps  also  in 
neurasthenic-like  states  of  psychopathic  patients,  and  in  a  less  pro- 
nounced degree  it  is  also  observed  transitionally  in  epileptic  twilight 
states.  It  is  often  connected  with  the  analogous  feelings  of  strange- 
ness in  regard  to  the  outside  world. 

In  schizophrenia  one  sees  a  great  many  forms  of  transformations 
of  personality  of  which  I  only  want  to  mention  a  few  types.  The 
patients  suddenly  imagine  that  they  are  Napoleon,  and  some  enter- 
tain the  idea  without  giving  up  their  past  life;  it  is  merely  an 
addition  to  their  past  life.  In  other  cases  they  shut  off  at  least  every- 
thing incompatible  with  the  delusion;  thus,  those  who  have  grandiose 
ideas  state  they  were  not  born  in  the  locality  in  question,  they  did 
not  go  to  school  there,  but  in  some  mysterious  way  circumstances 
forced  them  to  play  the  part  of  John  Smith  for  some  time,  but  now 
they  want  to  re-establish  their  sovereign  authority  over  Europe.  In 
other  cases,  the  former  personality  ceases  to  exist;  sometimes,  but 
by  no  means  always,  they  have  interwoven  the  past  of  Napoleon  with 
the  present  of  their  momentary  delusional  personality.  Others  have 
become  Christ,  or  even  God.  The  latter  mechanism  is  not  a  rare 
occurrence  in  paretic  patients,  but  in  most  cases  it  exerts  no  in- 
fluence whatever  on  their  actions,  whereas  schizophrenic  patients 
sometimes  may  act  in  accordance  with  the  change  of  personality. 
When  I  expressed  astonishment  that  he  knew  the  whole  Bible  by 
heart,  such  a  god  said  to  me  that  there  was  nothing  unusual  about 
it,  as  he  had  written  it  himself;  and  to  my  remark  that  it  was 
strange  that  we  perceived  nothing  of  his  omniscient  spirit,  he  an- 
swered that  he  had  sent  out  his  spirit  among  mankind,  and  now  so 
little  was  left  for  him  that  he  had  come  into  the  asylum,  but  that 


140  TEXTBOOK  OF  PSYCHIATRY 

he  could  recall  his  spirit  at  any  moment,  only  he  would  not  do  so 
out  of  compassion  for  poor  mankind.  Other  patients  imagine  them- 
selves transformed  into  animals  and  even  into  things,  and  yet  they 
usually  do  not  adhere  to  one  idea.  Just  as  a  patient  can  be  the 
Pope,  the  Emperor,  the  Sultan,  and  eventually  God  in  one  person, 
he  can  also  be  a  pig  and  a  horse.  Nevertheless  the  patients  rarely 
follow  up  the  logic  to  act  accordingly,  as,  for  instance,  to  bark  like 
a  dog  when  they  profess  to  be  a  dog.  Although  they  refuse  to  admit 
the  truth,  they  behave  as  if  the  expression  is  only  to  be  taken 
symbolically,  in  the  same  way  perhaps  as  when  a  man  is  insultingly 
called  a  pig. 

It  is  quite  an  ordinary  occurrence  to  see  schizophrenic  patients 
identify  themselves  in  the  most  illogical  way  with  people  whom  they 
love  or  admire.  Under  certain  conditions,  and  in  a  certain  sense, 
they  are  their  beloved,  they  had  the  same  experience  as  they,  and 
they  play  their  beloved's  part.  A  non-schizophrenic  patient  of  v. 
Krafft-Ebing,  who  loved  only  limping  women,  could  not  resist  the 
impulse  to  imitate  such  a  limping  woman. 

Some  schizophrenics  have  altogether  lost  their  personality.  For- 
merly they  have  been  so-and-so,  but  now  they  are  somebody  else, 
and  their  former  personality  may  be  in  some  other  person.  Under 
such  circumstances  it  may  happen  that  they  speak  of  themselves  in 
the  third  person,  for  they  have  the  feeling  that  they  are  no  longer 
the  person  whom  they  have  designated  as  "I." 

Temporary  transformations  of  the  person  into  another,  as,  for 
example,  into  potentates  or  saints,  occur  occasionally  in  the  different 
twilight  states. 

Nowadays  there  is  much  talk  about 'the  preservation  or  annihila- 
tion of  the  personality.  Kraepelin's  paraphrenics  are  supposed  to 
differ  from  schizophrenia,  the  arteriosclerotic  and  luetic  psychoses 
from  simple  senile  dementia,  and  the  latter  from  the  most  disturbed 
paretics,  in  the  fact  that  the  personality  is  fairly  well,  or  better  pre- 
served. By  that  we  understand  the  active  continuation  of  the  hitherto 
existing  strivings  and  aims  of  action,  as  well  as  of  the  more  important 
characteristics  in  general.  In  organic  diseases,  where  the  personality 
is  not  much  injured,  which  is  especially  the  case  in  arteriosclerotic 
insanity,  there  is  surely  no  lack  of  affective  changes  in  the  sense  of 
lability,  or  irritability,  but  the  patient  knows  something  about  it, 
and  he  even  often  endeavors  to  combat  his  faults.  Having  been  an 
honest  man  he  does  not  now  turn  into  a  scoundrel;  when  he  is  no 
longer  able  to  support  his  family  he  perceives  it  painfully,  and  his 
external  appearance  remains  relatively  good,  in  so  far  as  his  mental 


GENERAL  PSYCHOPATHOLOGY  141 

clearness  is  not  disturbed.  That  accounts  for  the  fact  that  these 
people  are  in  no  immediate  need  of  asylum  treatment,  and  when  they 
are  sent  there  it  is  frequently  only  in  consequence  of  a  single  special 
circumstance,  such  as  a  danger  of  suicide,  or  confusion. 

The  schizophrenic  disturbance  of  personality  is  much  deeper  and 
more  far  reaching.  Even  when  the  organic  patient  changes  into  a 
different  person  and  his  strivings  often  change  only  too  much,  yet 
what  he  feels  and  strives  for  in  a  single  moment  is  the  expression 
of  his  whole  actual  psyche.  On  the  other  hand,  the  schizophrenic 
may  at  the  same  time  strive  for  something  contradictory,  and  do  some- 
thing that  he  has  not  desired  and  even  despised.  His  personality  can 
divide  itself;  now  he  acts  and  thinks  like  a  great  man,  now  like  a 
scholar,  or  in  another  manner,  and  his  hallucinations  and  delusions 
then  also  correspond  to  it.  There  are  forever  different  strivings, 
which  embody  themselves  in  such  personalities.^^  Very  frequently 
the  direction  from  and  to  a  person  is  no  longer  distinguished.  A 
paranoid  patient  fears  in  her  depression  that  she  is  being  harmed; 
she  is  then  commanded  by  the  voices  to  help  others  instead  of  that 
help  should  be  given  to  her  as  might  have  been  expected.  Everyday 
experience  shows  that  both  ideas  are  identical  to  the  patient  and 
that  it  is  not  necessary  to  add  a  logical  connecting  link.  A  persecuted 
patient  wants  to  become  a  professor,  but  he  complains  that  people 
want  to  force  him  to  be  a  professor. 

In  severe  cases  of  schizophrenia,  a  high  degree  of  disintegration  of 
personality  results  because  the  uniform  striving  and  the  uniform 
memory  complex  become  destroyed;  the  patients  babble  and  show 
no  coherence  in  thoughts  and  wishes,  indeed  the  borderline  between 
their  own  person  and  the  environment  is  blurred.  As  in  appersona- 
tion  and  in  transitivism  concepts  which  do  not  belong  to  the  person 
become  connected  with  him,  and  vice  versa.  Thus  the  strongest  as- 
sociations may  finally  detach  themselves,  while  any  other  ideas  may 
become  associated  with  the  person,  if  in  such  cases  one  can  still  speak 
of  a  person  at  all. 

In  general,  the  schizophrenic  personality  suffers  in  the  follow- 
ing different  ways:  Through  dementia,  the  restrictions  or  perversities 
of  the  instinctive  life,  through  the  disturbance  of  the  uniform  direction 
of  the  striving  and  acting,  and  the  disturbances  of  will  which  force 
schizophrenics  into  actions  that  they  do  not  strive  for  at  all. 

In  most  of  the  disturbances  of  personality  one  deals  w'ith  a  split- 
ting in  the  direction  of  the  affective  needs,  that  is  to  say,  with  simple 
emotional  effects  which  in  themselves  are  verj^  violent,  or  become 

°-  Cf.  Complexes,  pp.  35-36. 


142  TEXTBOOK  OF  PSYCHIATRY 

overpowering  in  a  morbid  soil;  this  is  seen,  for  instance,  in  paresis, 
where,  owing  to  the  restriction  of  associations,  the  wish  to  be  God 
Almighty  is  put  into  reality  without  any  further  ado,  also  in  schizo- 
phrenia particularly  after  the  structure  of  associations  has  already 
become  loosened;  in  the  latter  cases  the  complexes  can  actually 
acquire  sub-personalities  with  some  sort  of  independence  within  the 
psyche.  Depending  on  the  circumstances  the  patient  is  this  or  that 
personality,  or,  what  is  still  more  frequent,  he  hears  in  the  voices, 
now  the  expression  of  this  complex  (the  wish  to  be  a  Prince) ,  and  at 
another  time  that  of  another  complex  (to  be  condemned  as  an  onanist). 
I  am  not  sufficiently  clear  about  depersonalization,  because  cases 
giving  reliable  information  are  not  very  common.  In  part  we  probably 
have  to  deal  with  the  same  process  which  we  see  in  the  melancholic 
patients,  to  whom  external  things  appear  strange,  perhaps  because  the 
feeling  components  are  so  strongly  falsified.  But  if  the  patients  are 
not  conscious  of  their  own  volition-impulse  it  must  be  due  to  the 
blocking  of  an  inner  feeling,  the  mechanism  and  causes  of  which  is 
not  just  clear. 

11.  DISTURBANCES  OF  CENTRIFUGAL  FUNCTIONS 

Actions  as  the  final  link  in  the  chain  of  psychic  processes  are 
naturally  inadequate  to  the  situations  if  the  sensations,  deliberations 
or  feelings  upon  which  they  depend  are  inadequate.  He  who  is  con- 
trolled by  false  perceptions,  and  imagines  that  robbers  are  breaking 
in  when  his  nurses  are  coming,  will  defend  himself.  Some  halluci- 
nations influence  the  patient  directly,  and  often  in  a  forceful  way; 
he  has  to  act  in  the  sense  of  the  hallucinations  even  if  he  realizes 
that  he  does  thereby  something  detrimental  to  himself  and  to  others. 
This  mode  of  action  does  not  always  need  the  form  of  commands. 
Thus,  a  periodic  patient  named  Mantel,  who  was  locked  in  his  room, 
repeatedly  heard  the  words:  "Mantel,  thou  strong  hero."  Whereupon 
he  reacted  by  demolishing  his  room,  to  show  his  annoyers  that  he 
was  really  so  strong.  To  be  sure,  the  hallucinations  instigate  only 
those  actions  for  which  a  tendency  already  exists;  but  this  does  not 
need  to  be  the  tendency  of  the  conscious  personality;  indeed,  it  may 
even  be  incompatible  with  it.  At  the  same  time  there  are  hallucina- 
tions foi  the  obedience  of  which  there  is  little  or  hardly  any  impulse, 
and  in  later  stages  of  schizophrenia  the  patients  regularly  refuse  to 
obey  their  hallucinations,  in  spite  of  the  fact  that  they  believe  in  them 
as  strongly  as  ever. 

The  so-called  hallucinatory  excitements  in  schizophrenia  are  also 


GENERAL  PSYCHOPATHOLOCiY  143 

worthy  of  mention;  here,  under  the  impresnion  (jf  false  perceptions, 
the  patients  suddenly  become  abusive,  strike  blindly,  or  commit  any 
other  acts  of  violence.  To  be  sure,  in  most  cases  one  does  not  know 
to  what  extent  the  hallucinations  are  only  a  part  of  the  symptoms  of 
the  whole  excitable  action,  and  to  what  extent  they  are  the  cause 
of  the  violent  outburst. 

If  thinking  is  disturbed  so  that  it  sets  incorrect  aims  toward  action, 
then  the  acts  also  are  false.  He  who  entertains  the  delusion  that 
people  want  to  poison  him  will  in  most  cases  react  to  it,  which  is  quite 
correct  from  his  viewpoint,  but  pathological  from  the  observer's.  An 
aimless  or  feeble-minded  thinking  will  condition  aimless  or  feeble- 
minded actions.  If  the  thinking  of  the  psychopathic  and  insane  devi- 
ates from  the  average  thinking,  it  means  in  most  cases  a  deterioration 
of  quality ;  the  actions  of  the  real  insane  persons  are  nearly  always  of 
inferior  quality  or  of  negative  value.  In  exceptional  cases,  however, 
and  especially  in  mere  psychopaths  the  anomaly  leads  to  new  values. ^^ 

Action  is  for  the  most  part  influenced  by  afjectivity,  if  one  at  least 
agrees  with  us  when  we  designate  the  force  and  direction  of  the  im- 
pulses, or  of  the  "will,"  as  partial  manifestations  of  the  affects.  He 
who  is  happy,  sad  or  furious,  will  react  accordingly.  Fear  can  make 
a  person  motionless  and  rigid  or  limp,  it  can  urge  him  to  aimless 
flight,  or  merely  to  a  restless  manifestation  of  the  affect,  such  as  rest- 
lessly walking  to  and  fro,  or  to  brutal  acts  of  violence.  The  last  named 
are  especially  striking  when  motility  is  otherwise  practically  absent 
and  the  anxious  or  depressed  patient  suddenly  gives  vent  to  his  feeling 
by  destroying  some  object  or  even  by  committing  a  murder.  Such 
reactions  to  unbearable  tension  are  designated  as  raptus.^^  The  ab- 
sence of  ethical  feelings  brings  to  the  surface  anti-social  actions. 
Lability  of  feelings  and  emotivity  make  the  actions  unsteady  and 
capricious.  Absence  of  feelings  in  general  or  weakness  of  the  same 
diminishes  the  impulses,  and  makes  them  weak.  The  expression 
"Weakness  of  Will"  designates  three  totally  different  things:  (1)  A 
lack  of  will  impulses  due  to  a  weakness  of  the  affect-s,  or  a  lack  of 
steam  pressure  in  the  engine,  abulia  as  a  result  of  apathy.  (2)  Incon- 
sistency of  the  aims  in  the  face  of  very  vivid,  but  too  labile  affects, 
which  make  its  bearer  dependent  on  outer  influences;  a  slight  push 
causes  the  engine  to  run  backwards  too  easily,  when  it  should  go  for- 
ward, which  is  due  to  the  fact  that  the  direction-switch  is  too  easily 
movable.     Frivolous   people   and   those   who   are  unable   to    act   in 

■"Comp.  remarks  on  Genius,  p.  171. 

"  There  is  also  a  raptus  in  schizophrenic  patients  which  is  merely  an  execution 
of  sudden  impulses  without  affective  tension. 


144  TEXTBOOK  OF  PSYCHIATRY 

accordance  with  their  own  resolutions  are  congenitally  weak-willed  in 
this  sense;  manic  and  organic  patients  become  so  through  their  illness. 
This  kind  of  weakness  of  will  can  also  be  ascribed  to  an  exaggerated 
suggestibility,  which  only  partly  coincides  with  the  lability  of  affects. 
(3)  Incapacity  to  make  decisions  through  counter  reflections  and  im- 
pulses in  persons  who  are  too  conscientious  and  too  deliberate  in 
everything,  and  in  those  who  are  in  a  depressed  state. 

Wherever  one  does  not  observe  any,  or  very  slight  expressions  of 
will,  one  speaks  of  stupor;  in  such  cases  thinking  is  usually  at  a  low 
ebb;  indeed,  in  some  states  the  disturbance  of  thought  as  such  may  be 
in  the  foreground  as  in  the  emotional  stupor  of  imbeciles.  Stupor  is 
no  uniform  syndrome,  but  an  outer  form  of  manifestation  of  the  fol- 
lowing different  states:  maximal  apathy,  inhibitions,  obstructions,  over- 
powering through  fright  or  anxiety,  and  cerebral  torpor  of  any  kind. 
Thus  we  find  stupor,  especially  in  schizophrenia  where  apathy,  block- 
ings, inhibitions,  and  sometimes  cerebral  torpor  appear  together,  fur- 
thermore in  epilepsy,  in  organic  diseases,  and  in  manic-depressive  inhi- 
bitions. Nevertheless,  in  regard  to  the  latter,  it  must  be  observed  that 
one  does  not  like  to  call  melancholic  inhibitions  stupor,  if,  as  is  usual, 
they  are  distinctly  connected  with  signs  of  severe  physical  pain. 
Melancholia  attonita,  as  it  was  formerly  called,  is  usually  a  catatonia, 
with  or  without  depression.  Stupor  resulting  from  strong  affects 
(emotional  stupor)  we  find  in  its  highest  development  especially  in 
hysteria,  and  to  a  lesser  degree  very  frequently  in  forms  of  congenital 
feeble-mindedness. 

A  hyper-function  of  the  will  in  the  sense  of  special  strength  is 
naturally  difficult  to  establish,  because  a  person  seems  to  us  the 
healthier,  the  stronger  his  will  is.  Yet,  in  hysterical  and  other  psycho- 
pathic cases  we  sometimes  see  a  force  of  impulse,  of  endurance,  and 
capacity  to  bear  pain,  which  far  exceeds  the  normal.  Also  schizo- 
phrenic patients  sometimes  develop  a  special  energy  or  will,  as,  for 
instance,  when  they  pull  out  their  own  teeth,  squeeze  out  one  of  their 
eyes,  or  do  something  similar  without  being  analgesic.  The  dissimu- 
lation of  symptoms  of  disease,  especially  in  melancholies,  points  to 
an  enormous  force  of  will.  The  occupation  urge  of  manic  patients  who 
constantly  want  to  do  all  sorts  of  things  and  accomplish  much  has 
also  been  regarded  as  a  hyperfunction  of  will.  We  also  mention  here 
the  hyperkineses  of  many  catatonic  patients  (see  below)  which  in 
everything  else  are  principally  separated  from  them. 

A  morbid  facility  of  the  capacity  to  make  decisions  is  observed  in 
manic  patients  and  under  mild  alcoholic  stimulation.  Also  in  affects 
which  compel  actions  such  as  fury,  or  fear,  but  here  it  is  naturally 


GENERAL  PSYCHOPATHOLOGY  145 

one-sided,  acting  only  in  the  direction  of  the  affect;  every  idea  which 
has  a  centrifugal  component  leads  straight  to  action.  The  possibility 
of  an  accurate  reflection  is  hereby  always  diminished;  the  actions 
become  precipitated.  If  reflection  is  primarily  inhibited  the  reverse 
is  the  case,  all  things  being  equal;  any  kind  of  stimulus  leads  to  action 
more  easily  and  more  quickly. 

The  ability  to  make  decisions  is  primarily  badly  impaired  in 
melancholic  states,  secondarily  it  is  still  more  diminished  through  the 
feeling  of  insufficient  reflection  and  especially  through  the  general 
unpleasant  accentuation  of  all  the  possible  objective  ideas.  If  the 
patient  is  inclined  to  go  in  the  open  air  he  feels  it  as  something  too 
terrible;  if  he  thinks  of  remaining  in  the  room,  that  too,  seems  just 
as  unbearable.  In  apathy  no  decision  can  be  taken,  because  the  im- 
pulse is  lacking;  the  same  is  the  case  in  torpor,  where  all  psychic 
processes  are  low.  In  states  of  obstruction,  as  long  as  it  exists,  the 
physical  processes  are  interrupted  either  altogether  or  especially  in  the 
direction  of  the  decision,  and  nothing  happens.  But  there  can  also  be 
too  much  thinking.  Whoever  inclines  to  take  into  account  every 
imaginable  possibility  can  hardly  arrive  at  a  conclusion.  A  certain 
onesidedness  is  necessary  in  action;  one  must  give  up  advantages  in 
big  or  small  matters  and  must  be  able  to  risk  something,  if  one  wants 
to  act  at  the  right  time  and  with  the  necessary  force.  The  ambivalence 
of  the  feeling  tone  ^*  is  an  obstacle  to  the  decision.  If  one  loves  and 
hates  at  the  same  time  without  summing  up  the  positive  and  negative 
feelings  into  a  unified  difference,  one  is  torn  to  both  sides  and  does  not 
get  any  results  even  in  deciding.  The  so-called  psychomotor  ex- 
citements and  inhibitions  naturally  concern  the  whole  psyche;  in  any 
case  they  are  not  strictly  confined  to  motility,  but  distinctly  influence 
also  the  need  for  action,  the  ability  to  make  decisions,  and  the  facility 
of  the  transition  of  the  excitement  over  the  true  centrifugal  paths. 
The  manic  pressure  activity  (the  urge  to  occupy  oneself)  expresses 
itself  in  the  fact  that  the  patients  can  never  permit  themselves  to 
rest;  something  has  to  happen  all  the  time.  In  milder  cases  it  is 
merely  a  quantitative  increase  of  action  that  is  observed,  which  can 
also  be  accomplished  by  a  normal  person,  such  as  an  increase  of  busi- 
ness activity  or  similar  acts ;  in  more  severe  cases  it  comes  to  excesses ; 
thus  one  notes  a  thoughtlessness  in  all  spheres  of  action,  and  finally 
there  is  a  destruction  of  objects  and  a  building  up  of  new  combina- 
tions from  the  material  acquired;  there  is  a  constant  smearing, 
screaming,  jumping  and  similar  acts.  Taken  singly,  the  aims  usually 
change  very  quickly  under  these  conditions;  nothing  is  finished,  and 
"  Cf.  p.  125. 


146  TEXTBOOK  OF  PSYCHIATRY 

even  in  mild  cases  one  notes  a  lack  of  perseverance  in  the  business 
enterprises  of  manic  patients.  The  pressure  activity  is  naturally  also 
disburdened  through  talking.  The  patients  are  very  talkative  and 
they  can  not  really  get  away  from  their  talking  which  becomes  more 
and  more  incoherent  {LogorrhoBa) . 

The  depressive  inhibition  of  action  causes  actions  to  be  avoided  as 
far  as  possible,  in  more  severe  cases  altogether,  or  if  motions  and 
actions  still  exist,  they  represent  the  monotonous  discharge  of  the 
dominating  affect,  especially  that  of  anxiety. 

The  highest  degree  of  inhibition  of  motion  is  designated  as  attonity. 
For  long  periods  the  patients  really  make  no  active  movement.  They 
have  to  be  dressed  and  undressed  like  puppets,  they  have  to  be  fed 
with  a  spoon  or  even  with  the  tube,  their  saliva  is  not  swallowed,  but 
drools  from  the  corners  of  their  mouths,  and  even  the  movements  of 
the  eyelids  can  stop.  Such  states  nearly  always  belong  to  the  schizo- 
phrenic stupor,  especially  of  the  depressive  type. 

There  exists  also  a  simple  schizophrenic  akinesis,  which  we  cannot 
at  present  very  well  refer  to  other  disturbances  because  the  accom- 
panying symptoms  seem  insufficiently  developed.  In  contrast  to  this 
we  have  the  schizophrenic  hyperkinesis  where  the  patients  are  in  con- 
stant motion,  but  yet  do  not  seem  to  "act."  Without  any  apparent 
reason,  as  far  as  we  can  learn,  without  any  motive  known  to  them- 
selves, they  are  actively  violent,  they  are  destructive,  they  throw 
themselves  or  only  their  limbs  in  the  air,  they  play  tricks,  etc.  Never- 
theless, both  subjectively  and  objectively  the  action  appears  to  be  in- 
tended: it  is  a  psychic  motion  impulse  without  motive,  one  might  say, 
a  kind  of  convulsion  of  psychomotility  (but  not  at  all  a  motor  spasm 
in  the  usual  sense).  The  mere  pressure  motion  shovM  he  distinctly 
differentiated  from  the  pressure  occupation  of  the  manic  patients 
which  always  has  a  meaning.  The  attempt  has  been  made  to  classify 
also  verbigeration  as  an  analogous  "cramp  of  the  speech  centre,"  but 
it  is  not  particularly  often  combined  with  hyperkinesis. 

The  concept  of  jactation  refers  more  to  the  outward  appearance. 
Here  also  we  deal  with  mere  motions,  which  are  especially  weak;  at 
most  they  represent  rudiments  of  actions  and  have  quite  different 
causes.  Under  certain  conditions  hyperkinetic  states  in  the  sense  just 
now  described  may  be  called  jactations;  the  term  may  also  be  applied 
to  agitation  caused  by  fear  or  other  uncomfortable  feelings,  or  the 
tossing  about  in  pain;  but  the  concept  corresponds  best  to  the  move- 
ments in  cerebral  irritations,  as  seen  in  meningitis  or  acute  delirium. 

In  schizophrenia  there  is  sometimes  a  motor  parafunction  which 
actually  calls  to  mind  apraxia,  but  at  all  events  it  is  not  genetically 


GENERAL  PSYCHOPATIIOLOGY  147 

analogous  to  the  organic  syndrome  of  this  name;  it  resembles  more  the 
opposite  actions  produced  during  shock  or  distraction:  Thus,  the 
patient  wants  to  put  the  spoon  into  the  phice,  but  with  uncertain  move- 
ments he  takes  it  in  a  strange  way  first  in  one  hand,  then  in  the  other, 
where  he  turns  it  around,  until  at  last  he  places  it  on  his  knee;  or 
instead  of  the  spoon  he  grasps  anything  else  which  happens  to  be  at 
hand.  When  walking,  his  legs  move  in  an  uncertain  way,  in  various 
long  steps,  not  exactly  towards  the  goal.  Kraepelin  grouped  analogous 
disturbances  of  a  lighter  grade  under  the  term:  "loss  of  gracefulness." 
As  the  patient  is  simultaneously  moved  by  different  feelings,  and  as 
they  are  badly  suited  to  the  ideas,  all  actions  often  appear  unreal, 
artificial,  and  affected,  and  as  the  associations  of  ideas  also  in  regard 
to  the  carrying  out  of  the  movements  do  not  proceed  in  usual  paths, 
they  acquire  something  of  the  bizarre.''^ 

Sometimes  movements,  that  is,  actions,  become  stereotyped,  in 
which  case  quite  different  mechanisms  may  come  into  play.  Catatonic 
patients  sometimes  cannot  get  through  with  a  movement  manifoldly 
repeated,  such  as  wiping  the  face,  or  scooping  up  their  soup,  or  they 
do  not  think  of  stopping  even  after  they  have  finished  these  acts.  A 
strong  accompanying  affect  can  easily  stereotype  an  action  which  then 
continues  to  repeat  itself  without  any  voluntary  effort  on  the  part  of 
the  patients.  In  the  course  of  time,  it  generally  becomes  more  or  less 
shortened  in  form,  or  it  changes  in  regard  to  place.  Thus  an  original 
onanistic  movement  of  the  pelvis  may  finally  change  into  a  shaking  of 
the  head.  In  this,  and  in  still  other  ways  stereotyped  movements 
originate  in  catatonic  patients,  which  often  last  for  decades  and  seem 
absurd  to  the  patient  as  well  as  to  the  observer.  Customary  acts  may 
undergo  changes  which  then  become  stereotyped.  For  example,  the 
patient  taps  seven  times  on  his  coat  at  every  button  he  is  about  to 
close;  he  shakes  hands  in  quite  a  strange  way  {Variation  stereotypes, 
mannerisms) . 

There  are  still  other  mannerisms  besides  the  variation  stereotypes 
of  which  the  following  may  be  mentioned:  independent  clownish  ges- 
tures, spreading  out  of  fingers,  also  bizarre  expressions  of  every  de- 
scription, exaggerated  style  of  dress  and  hair,  caricatured  elegance  and 
finally  morbid  expressions  of  affects,  exaggerated  pathos,  and  self- 
satisfied  attitude;  in  short,  the  patient  evinces  all  the  faults  of  a  bad 
actor.  As  many  show  an  indication  of  these  changes  at  puberty,  an 
attempt  was  made  to  regard  them  as  symptoms  of  puberty,  which  were 
fixed  and  exaggerated  by  the  disease. 

When  language  becomes  stereotyped  it  is  called  verbigeration. 
"  Cf.  below,  "mannerisms." 


148  TEXTBOOK  OF  PSYCHIATRY 

Here  quite  senseless  words  and  sentences,  at  least  for  the  actual  situa- 
tion, are  constantly  repeated,  often  in  a  striking  tone  which  is  also 
stereotyped. 

Besides  the  stereotypes  of  motion  there  are  those  of  posture,  the 
patients  always  assuming  exactly  the  same  position, — and  of  place; 
they  want  to  sit,  or  stand,  or  walk  always  in  the  same  place.^'' 

The  stereotypes,  in  the  sense  amplified  so  far,  belong  to  the  cata- 
tonic symptoms,  and  outside  of  schizophrenia  occur  perhaps  also  in 
organic  patients;  but  it  is  not  at  all  certain  that  they  are  then  geneti- 
cally of  the  same  value.  In  any  case  the  perseveration  in  the  organic 
patients,  which  we  see  most  typically  in  coarse  brain  lesions,  especially 
in  aphasic  patients,  is  something  quite  different  from  stereotypes.  The 
patients  cannot  rid  themselves  of  a  word  which  they  have  just  heard, 
or  which  they  have  just  said,  and  repeat  it  constantly  when  they  wish 
to  say  something  else.  And  even  when  the  patients  execute  a  simple 
action,  such  as  wishing  merely  to  think  of  something,  this  impulse  may 
under  certain  conditions  proceed  against  their  will  in  the  path  of  the 
preceding  action,  or  in  the  one  thought  of  immediately  before. 

Other  stereotype-like  manifestations  are  the  homogeneous  actions, 
which  some  epileptic  patients  perform  in  post-epileptic  twilight  states, 
the  repetitions  of  terrifying  experiences  through  hallucinations,  and 
(mostly  abbreviated)  actions  in  the  twilight  states  of  the  hysterical 
patients.  The  manifestation  of  a  lasting  strong  affect,  like  the  stereo- 
typed screaming  or  wailing  of  depressed  organic  patients,  the  tics, 
some  actions  which  have  become  automatic,  and  the  movements  of 
idiots, — all  these  movements  which  outwardly  resemble  the  schizo- 
phrenic stereotypes  have  quite  a  different  genesis  and  meaning. 

Paraf unctions  of  the  will  attach  themselves  mainly  to  the  so-called 
impulses.  The  nutrition-impulse  has  been  stunted  in  the  cultural  being 
who  rarely  feels  real  hunger,  and  when  he  wants  to  starve  himself  to 
death  he  is  forcibly  fed.  This  impulse  is  also  very  indirectly  satisfied, 
in  so  far  as  one  learns  to  write  at  the  age  of  six,  in  order  to  earn  his 
living  from  ten  to  twenty  years  later.  Even  the  impulse  of  self-preser- 
vation in  general  is  no  longer  at  its  height  with  us,  either  with  regard 
to  the  individual,  or  his  family,  or  his  race.  The  suicide-impulse, 
which  under  simpler  circumstances  very  rarely  occurs  even  in  patho- 
logical conditions,  has  become  a  calamity  in  our  asylums.  The  sex 
impulse  has  been  preserved  only  in  some  measure  of  its  original  form, 
and  is  pushed  back  by  culture  in  different  ways,  such  as  through 
chastity,  monogamy,  asceticism,  and  birth  control.  But  this  impulse 
breaks  through  with  elemental  force  and  creates  in  the  individual  those 

'"'  For  more  details  Cf .  chapter  on  Schizophrenia, 


GENERAL  PSYCHOPATHOLOGY  149 

inner  conflicts  whicii  mostly  become  pathogenic.  Preserved  is  tiie 
ethical  or  the  altruistic  impulse,  although  just  now  it  is  being  subjected 
to  a  certain  transvaluation.  In  place  of  the  primary  impulses  there 
are  others,  which  are  particularly  active,  such  as  the  impulse  for 
knowledge,  and  tend  more  towards  the  preservation  of  civilization 
than  life. 

The  morbid  disturbances  of  the  nutrition-impuhe  are  not  so  im- 
portant in  psychiatry.  Beside  excessive  gluttony  of  the  paretic  and 
idiots,  we  find  in  depressions  and  in  catatonics  a  peculiar  lack  of 
appetite;  indeed  there  is  an  aversion  to  eating  and  drinking  resulting 
in  a  total  abstinence  for  any  length  of  time.  Besides  these,  nervous 
patients  evince  peculiar  cravings  (picae) ,  and  schizophrenics  a  ten- 
dency to  swallow  all  kinds  of  things,  even  their  own  excrement  (copro- 
phagia),  which  is  sometimes  accompanied  by  gustatory  enjoyment  and 
sometimes  not. 

The  sex-impulse  has  a  special  pathology,  which  will  be  dealt  with 
in  the  special  psychiatry.  The  ethical  impulse  varies  constitutionally 
from  the  "genius  of  altruism"  to  the  moral  idiot,  who  is  devoid  of 
all  altruistic  feelings. 

The  expression  "impulse"  has  quite  a  different  meaning,  if  one 
speaks  of  "morbid  impulses."  In  most  cases  this  word  refers  to  the 
impulses  for  actions,  which  are  accomplished  unexpectedly,  without 
real  reflection  or  with  inconsistent  reflection,  or  without  the  assent 
of  the  whole  personality.  Such  actions  are  often  distinguished  by 
violence,  hastiness,  skill,  and  regardlessness  of  the  interests  of  others, 
as  well  as  of  their  own.  But  even  under  the  name  of  impulsive  actions, 
one  includes  chiefly  different  symptoms  of  various  grades.  Thus  one 
speaks  of  the  morbid  impulse  to  set  fire  to  places  {Pijrornania) ,  of 
the  stealing  impulse  {Kleptomania),  the  murder  impulse  and  similar 
pathological  states.  These  disturbances  will  be  described  later  on  under 
the  heading  of  "Impulsive  Insanity." 

All  impulsive  actions  have  one  thing  in  common,  namely,  they  are 
carried  out  without  the  cooperation  of  reflection  and  aimful  willing. 

The  expression  "Impidsive  Actions"  expresses  only  a  part  of  the 
same  thing,  that  is,  it  refers  to  various  indefinable  kinds  of  actions 
carried  out  suddenly  and  without  proper  deliberation.  This  may  be 
in  the  form  of  incomprehensible  "afTective-actions"  in  emotional  per- 
sons, or  actions  which  are  conditioned  by  inner  motives  of  which  the 
subject  himself  is  not  sufficiently  conscious,  and  this  is  especially  the 
case  in  schizophrenics.  Some  sudden  obsessive  actions  are  also  often 
inaptly  called  impulsive,  and  of  course  also  the  raptus  observed  in 
melancholies. 


150  TEXTBOOK  OF  PSYCHIATRY 

Certain  pathological  actions,  like  obsessive  and  automatic  actions 
are  abnormally  related  to  consciousness  or  to  the  will. 

Obsessive  actions  are  conscious  actions  running  counter  to  one's 
own  will,  and  proceed  from  an  inner  impulse  which  the  personality 
cannot  resist.  In  most  cases  the  resistance  is  connected  with  fear 
or  some  other  vague  uneasiness,  to  the  influence  of  which  the  per- 
sonality finally  yields,  in  the  same  way  as  a  physical  pain  forces  a 
person  to  do  something  which  he  does  not  wish  to  do. 

Impulses  tov/ards  indifferent  actions,  to  the  extent  of  compulsive- 
like exclamations  of  indecent  or  sacrilegious  words  (Coprolalia),  occur 
frequently  in  different  states.  In  so  far  as  they  refer  to  serious  crimes, 
like  murder  of  relatives,  they  are  rarely  irresistible  outside  of  schizo- 
phrenia. Indeed,  one  deals  most  frequently  with  apprehensions  lest 
one  might  do  something,  rather  than  with  real  impulses.^^  To  be  sure, 
those  apprehensions  are  nothing  but  effects  of  impulses  repressed  into 
the  unconscious. 

Automatic  Actions  are  not  directly  noticed  by  the  patient  himself: 
he  neither  feels  that  he  wishes  to  accomplish  the  action,  nor  that  he 
executes  it.  If  the  action  lasts  for  some  time,  he  takes  notice  of  it 
like  a  third  person,  by  observing  and  listening.  This  occurs  in  schizo- 
phrenia, where  in  this  way  windowpanes  are  frequently  broken, 
clothes  torn,  and  beating  administered,  but  automatic  actions  may  also 
be  present  in  an  especially  clear  formation,  in  forms  of  hysteria  and 
in  artificial  trance-states,  where  they  may  appear  in  complicated  and 
senseful  actions.  Here  the  mouth  speaks,  reproduces  apparently  the 
thoughts  of  the  spirit,  preaches,  and  the  hand  writes.  Most  people 
can  apparently  be  quickly  educated  to  automatic  writing  by  skilful 
suggestors ;  I  know  of  a  quack  who  made  all  his  patients  automatically 
write  out  their  diagnosis  and  the  remedies  to  be  applied.  Every 
"medium"  in  spiritistic  circles  does  automatic  speaking,  and  in  re- 
ligious epidemics  (preachers  in  the  Cevennes  and  others)  automatism 
draws  quite  a  large  circle  of  followers.  It  is  easy  to  understand  that 
such  people  acquire  the  idea  that  they  are  possessed  of  a  spirit 
(Demonism) .  If  the  latter  expresses  what  they  consciously  think  or 
wish,  then  it  is  a  good  spirit,  otherwise  it  is  a  bad  one;  it  is  not  at  all 
unusual  to  observe  that  the  patients  frequently  have  to  do  exactly  just 
what  they  do  not  want  to  do  as,  for  instance,  to  utter  ugly  or  sinful 
words  [Automatic  Coprolalia). 

A  very  good  description  of  a  schizophrenic  patient  is  the  following: 

"Suddenly  Dolinin  (the  writer  himself)  felt,  that  not  only  without 
his  wish,  but  even  against  his  will,  his  tongue  begins  to  express  loudly 
"Cf.  obsessive  ideas,  and  Compulsion  Neurosis,  p.  87. 


GENERAL  PSYCHOPATHOLOGY  151 

and  at  the  same  time  most  rapidly  that  which  in  no  case  should 
have  been  uttered.  At  the  first  moment  the  patient  was  perplexed 
and  frightened  by  the  very  fact  of  this  unusual  occurrence,  because  to 
be  suddenly  and  obviously  aware  of  a  wound  up  automaton  in  oneself 
is  per  se  disagreeable,  but  when  he  began  to  grasp  the  meaning  of  what 
his  tongue  chattered,  the  horror  of  the  patient  increased,  because  it 
showed  that  he,  D.,  openly  confesses  his  guilt  to  a  serious  political 
crime,  sometimes  ascribing  such  plans  to  himself  which  he  had  never 
entertained.  Notwithstanding  this  fact,  his  will  did  not  have  the 
power  to  restrain  his  tongue,  which  had  suddenly  become  automatic}'^ 

Within  the  automatic  actions  there  are  different  mechanisms.  It 
may  happen  that  something  is  executed  which  the  patient  wishes  to 
do,  but  he  does  not  feel  the  will  impulse  nor  its  accomplishment. 
When  he  wants  to  eat,  to  give  his  hand,  to  walk,  or  when  he  merely 
would  be  ready  to  do  so,  his  limbs  carry  out  the  action,  and  yet  he 
has  not  the  feeling  that  it  has  been  accomplished  at  his  instigation 
(in  schizophrenia).  His  limb  can  also  carry  out  something,  his  mouth 
can  say  something,  which  the  patient  might  not  wish.  He  feels  the 
impulse,  wants  to  resist,  but  has  no  power;  the  innervation  of  his 
muscles  is  directed  by  another  will.  From  this  there  are  all  transi- 
tions to  the  obsessive  actions,  and  the  other  will  is  naturally  not  a 
strange  one,  but  a  repression  of  the  patient's  own  striving  (in  Hys- 
terics, Schizophrenia).  Not  a  few  automatic  actions  remain  also 
unconscious  in  execution,  for  instance,  when  a  hysterical  woman 
crushes  rose  leaves  against  her  temple  during  conversation  as  a  symbol 
of  the  thought  of  her  lover's  death,  who  shot  himself  through  his 
temple.  Such  automatisms  may  also  be  the  prototype  of  many  schizo- 
phrenic stereotypes. 

Automatic  actions  which  are  formed  by  practice  evidently  have 
quite  different  mechanisms.  In  walking,  riding,  cycling,  piano  play- 
ing and  indeed  in  all  our  occupations  we  carry  out  a  number  of  simple 
actions  which  we  neither  start  consciously  nor  direct  consciously.  As 
a  rule,  these  are  willed  actions,  but  not  always;  somebody  may  do 
something  which  he  w^ould  not  carry  out  consciously,  as  to  pick  his 
nose  in  company,  to  show  a  sign  of  disdain,  and  similar  acts. 

Similar  to  such  actions  are  some  of  the  apparent  stereotypes  of 
organic  patients  which  evidently  pass  off  automatically  in  most  cases, 
but  represent  actions  which  already  have  been  practised  before  the 
disease,  like  the  incessant  twirling  of  the  moustache,  etc. 

The  list  can  still  be  completed  by  some  types  w^hich   although 

^  Kandinsky  in  Jaspers,  AUgemeine  Psychopathologie,  p.  121.  Julius  Springer, 
Berlin,  1913. 


152  TEXTBOOK  OF  PSYCHIATRY 

markedly  differing  from  each  other,  however,  have  these  in  common: 
sometimes  they  are  carried  out  quite  consciously,  sometimes  quite  auto- 
matically, sometimes  they  are  done  only  in  partial  consciousness;  and 
sometimes  they  are  only  the  expression  of  a  mood.  The  twirling  of 
thumbs,  scratching  of  the  head  in  healthy  people,  and  the  swaying  of 
idiots  represent  some  examples. 

Just  as  in  outer  actions,  thinking  also  may  proceed  compulsively 
or  automatically,  without  and  against  the  will  of  the  patient.  If  an 
idea  continually  keeps  on  obtruding  itself  against  the  will,  we  deal  with 
an  obsessive  idea.  But  beside  this  form  of  obsessive  thinking  there  is 
another  quite  different  form  of-  compulsive  thinking,  which  only  occurs 
in  schizophrenic  patients,  and  rarely  in  epileptic  equivalents  where 
the  patients  feel  that  "it"  thinks  in  them  often  the  same  thoughts 
that  they  themselves  think  spontaneously,  but  often  the  thoughts 
are  quite  different;  sometimes  there  is  a  confused  crowding  as  in  the 
"thought  crowding"  of  schizophrenic  patients.  Hence  in  such  cases 
the  thought  process  as  well  as  its  contents  are  withdrawn  from  the  will. 

The  theory  of  the  automatic  actions  can  easily  be  understood  from 
our  conception  of  psychic  processes.  The  associative  connection 
between  the  conscious  ego-complex  and  the  functions  of  acting  is  lack- 
ing. The  impulses  to  action  are  direct  effects  from  the  unconscious 
acting  upon  the  motor  functions.  The  complexes  from  which  they 
logically  originate  can  be  demonstrated  by  the  analyses  of  accessible 
patients.  Automatic  actions  of  various  kinds  can  be  experimentally 
produced  in  hypnosis. 

Half  automatic,  though  to  a  certain  insufficient  extent  accessible  to 
the  will,  are  the  tics,  which  according  to  Oppenheim  are  movements 
of  a  reflex,  defensive,  or  expressive  nature,  which  have  deteriorated 
into  compulsive  acts;  among  these  we  have  the  displaying  of  the 
teeth,  clenching  of  fists,  and  closing  of  eyelids.  They  are  morbid 
because  they  are  repeated  again  and  again  without  apparent  motive. 
The  patient  can  resist  the  impulse  for  a  short  time,  but  not  for  very 
long.     Tics  are  naturally  quite  stereotyped. 

The  impulse  for  an  action  carried  out  sometimes  consciously,  and 
sometimes  compulsively,  can  also  come  from  without,  as,  for  instance, 
in  automatic  obedience,  that  is,  the  compulsive-like  or  also  automatic 
obedience  to  requests  for  simple  actions  of  all  kinds.  The  patients 
carry  out  any  commands  whatsoever,  even  also  if  it  is  against  their 
will,  as,  for  example,  putting  out  their  tongue  when  they  know  that 
a  pin  will  be  stuck  into  it  (Schizophrenia).  The  impulse  for  such  an 
action  can  also  be  given  by  means  of  example  alone,  as  in  echopraxia 
and  echolalia.    Although  this  symptom  is  so  closely  related  to  auto- 


GENERAL  PSYCHOPATHOLOCJY  153 

matic  obedience  that  Kraepelin  makes  it  a  part  of  it,  I  have  never 
seen  the  two  peculiarities  run  parallel  in  development.  The  echo- 
practic  patients  imitate  whatever  strikes  them  in  the  actions  or  words 
of  their  surroundings.  As  far  as  we  know,  it  is  partly  a  question  of 
hysteria-like  mechanisms,  as  seen  in  the  echopraxia  of  primitive  peo- 
ple,"^^  and  certainly  in  most  cases  of  schizophrenia,  and  partly  a  matter 
of  an  incapacity  to  get  away  from  a  conceived  idea,  so  that  instead 
of  giving  an  answer  the  question  is  repeated,  or  instead  of  a  new  action 
the  preceding  act  is  imitated  (organic  echolalias  and  echopraxias). 
In  the  latter  case  the  patients  usually  wish  to  do  or  to  say  something 
quite  different,  but  the  impulse  turns  into  a  wrong  path.  In  hysteri- 
form,  or  schizophrenic  echopraxias,  the  person  does  not  "wish"  to  do 
something  different;  it  is  not  a  question  of  a  derailment  of  an  impulse 
actually  desired,  but  of  an  influence  of  the  conscious  or  unconscious 
wish  itself. 

According  to  Kraepelin,  the  phenomenon  of  fiexibilitas  cerea  (wax- 
like flexibility),  also  commonly  called  catalepsy,  also  belongs  to  auto- 
matic obedience.  The  patients  make  no  movement  of  their  own  voli- 
tion; but  if  they  are  placed  in  no  matter  how  uncomfortable  an  attitude 
they  maintain  it  for  a  very  long  time.  Thus,  the  patient  can  hold  his 
limbs  in  an  extended  posture  for  a  much  longer  time  than  a  normal 
person  could  do  voluntarily;  usually  they  gradually  sink  without 
trembling,  and  without  any  evident  exertion  on  the  part  of  the  patient. 
Some  patients  ofTer  a  certain  resistance  to  the  passive  moving  of  their 
limbs,  which  gives  the  impression  as  if  a  wax  statue  was  modelled. 
Most  patients,  however,  move  their  limbs  at  a  slight  push,  as  they 
guess  what  is  wanted  of  them. 

Much  more  frequently  one  finds  in  patients  whose  movements  are 
obviously  quite  normal,  that  if,  for  instance,  an  arm  is  somewhat 
brusquely  raised  upwards,  it  remains  so  for  a  long  time  {Pseudo- 
flexibilitas). 

The  schizophrenic  and  hysterical  catalepsy  can  be  psychically  in- 
fluenced to  a  high  degree,  which  makes  it  probable  that  it  is  essentially 
a  psychic  symptom;  still  there  is  a  probability  of  its  being  based  on  a 
peripheral  tendency  to  tonic  muscular  disturbances.  The  other  forms 
are  too  little  known. 

Besides  the  flexible,  there  exists  also  a  rigid  catalepsy.  Patients 
evincing  a  stereotyped  attitude  must  naturally  keep  the  corresponding 
muscles  in  constant  tone,  and  every  passive  change  of  the  same  is 
often  energetically  resisted,  giving  the  appearance  of  a  wooden  statue. 

™  In  the  Malays  thp  compulsory  imitation  of  simple  actions  is  described  as 
Latah,  in  Siberian  tribes  as  Miryachit. 


154  TEXTBOOK  OF  PSYCHIATRY 

The  apparent  counterpart  of  automatic  obedience  is  negativism, 
which,  however,  frequently  appears  with  symptoms  of  automatic  obedi- 
ence, Negativistic  patients  refuse  to  do  exactly  what  is  requested 
or  expected  of  them  (Passive  negativism),  or  they  do  the  opposite 
(Active  negativism) ,  so  that  in  pronounced  cases  it  is  possible  to  direct 
them  by  requesting  the  opposite  of  what  is  wanted  of  them.  Nega- 
tivism is  often,  but  not  always  connected  with  an  irritated  response 
to  all  influences  from  without,  and  consequently  with  a  tendency  to 
anger  and  violence.  Not  infrequently  negativism  expresses  itself  in  the 
fact  that  the  patients  make  an  effort  to  start  an  action,  when  a 
counter-impulse,  or  only  a  mere  blocking  appears  and  hinders  them 
in  its  execution.  It  is  also  probable  that  quite  different  impulses 
(cross-impulses)  interfere.  In  this  way,  negativism  can  also  express 
itself  against  its  own  impulses  (Inner-negativism).®* 

Centrifugal  disturbances  have  especially  many  relations  to  schizo- 
phrenia while  they  recede  in  other  diseases,  or  only  appear  as  a  natural 
consequence  of  other  disturbances.  The  schizophrenic  morbid  pictures 
in  which  they  appear  in  the  foreground  are  called  catatonias,  and 
the  symptoms,  which  associate  here  particularly  often  in  various  com- 
binations, are  called  catatonic  symptoms.  But  the  latter  partly  in 
other  genesis,  and  partly  in  a  somewhat  different  form,  may  also  occur 
now  and  then  in  other  diseases.  Catatonic  symptoms  are:  stereotypes 
(of  action,  of  attitude,  of  space,  and  verbigeration) ,  mannerisms,  auto- 
matic commands  with  waxlike  and  rigid  catalepsy,  echokinesis  and 
echolalia,  mutism  (see  below) ,  negativism,  impulsive  raptus,  the  cata- 
tonic form  of  stupor,  and  the  disturbances  of  the  will  in  the  stricter 
sense. 

In  general  the  will  is  indirectly  influenced  by  the  disturbances  of 
perceptions  and  thinking,  and  more  directly  by  disturbances  of  the 
affects.  In  catatonia  there  are  disturbances  of  the  will  in  a  different 
sense.  What  we  call  will  seems  to  merge  independently  into  wrong 
paths.  The  patients  cannot  do  what  the  conscious  part  of  their  ego 
would  wish,  they  cannot  will  what  they  recognize  as  good;  yet  these 
actions  are  not  automatic,  but  conscious,  and  in  a  certain  respect  they 
are  also  willed  by  a  split  off  part  of  the  will.  The  following  disturb- 
ances have  here  been  particularly  emphasized:  Hyperkinesis  and 
akinesis,  impulsive  actions,  automatisms,  negativism,  and  obsessive 
actions. 

The  ajfective  manifestations  inadequate  to  the  feeling  belong  al- 
most entirely  to  schizophrenia.  What  impresses  us  in  the  affective 
conduct  of  the  patient  outside  of  schizophrenia  is  conditioned  by  the 
'"  For  further  details  about  negativism  Cf .  Schizophrenia. 


GENERAL  PSYCHOPATHOLOGY  155 

abnormity  of  the  affect  itself;  an  exaggerated  manifestation  is  based 
on  an  exaggerated  affect.  In  schizophrenia  one  cannot  so  easily  judge 
from  without  to  within:  behind  a  tragic  pathos  there  may  be  a  very 
light  or  even  no  affect  at  all.  At  the  same  time  the  manifestations 
easily  strike  a  false  note  which  is  often  sensed  with  true  instinct  by 
naive  persons,  and  by  very  small  children.  Very  frequently  one  ob- 
serves an  unmotivated  laughter,  which  sounds  artificial,  and  from 
which  we  can  easily  recognize  that  it  is  not  the  expression  of  a  real 
gaiety.  It  can  also  be  easily  distinguished  from  the  convulsive  laugh- 
ter of  hysterical  patients.  In  lesions  of  the  thalamic  regions  one  finds 
occasionally  obsessive  laughter  or  crying  in  consequence  of  any  psychic 
stimuli  with,  or  particularly  without,  a  corresponding  affect. 

The  abnormities  of  the  mental  trend  are  naturally  expressed  in 
the  content  of  speech.  It  is  noteworthy,  however,  that  not  only  in 
aphasic,  but  also  in  schizophrenic  patients,  the  speech  utterances  may 
be  quite  incomprehensible  {confusion  of  speech,  "word  salad,"  schizo- 
phasia), while  the  corresponding  thoughts  remain  clear  as  shown  by 
the  orderly  behavior  and  work  of  the  patients. 

Formally,  the  vivid  speech  of  the  manic  patient  expresses  his 
euphoric  excitement,  the  retarded  and  low  speech  of  the  melancholic 
his  depressive  inhibitions,  the  babbling  and  stammering  speech  of  the 
idiot  his  sensory  and  motor  awkwardness,  the  inarticulate,  syllable 
stumbling  speech  of  the  paretic,  his  disturbances  of  coordination,  and 
the  hesitating,  singing  speech  of  the  epileptic,  the  dullness  of  his  affect 
and  mental  stream.  The  different  dysarthrias  in  apoplexy  and  other 
organic  disturbances  of  the  brain  do  not  directly  belong  to  our  field 
of  research,  as  they  are  only  accidental  complications  of  the  psychoses. 

A  persistent  not  speaking  is  called  mutism;  it  is  variously  deter- 
mined by  negativism,  delusions,  and  by  hallucinatory  prohibitions  to 
speak,  but  mainly  by  the  fact  that  schizophrenic  patients  have  nothing 
to  communicate  to  their  environment,  and  that  they  do  not  even  take 
notice  of  questions  put  to  them. 

The  handwriting  shows  quite  analogous  disturbances.  Orthographic 
and  grammatical  mistakes,  wrong  corrections,  and  blots,  give  evidence 
of  the  patient's  psychic  defects.  Imbecilic  awkwardness  and  paretic 
disturbances  of  coordination  impress  on  the  handwriting  a  mark  which 
is  easily  recognizable;  the  same  is  true  of  the  manic  mobility  and 
excitability  as  well  as  of  the  melancholic  inhibition.  Some  schizo- 
phrenic handwritings  contain  all  kinds  of  strange  letters  and  flourishes, 
orthographic  peculiarities,  abnormal  formations  of  lines  mixed  with 
unintelligible  signs,  and  similar  peculiarities.  The  content  of  the  writ- 
ings gives  us  just  as  important  enlightenment  as  regards  the  psychic 


156  TEXTBOOK  OF  PSYCHIATRY 

life  of  the  patient  as  the  spoken  utterances;  often  it  is  even  more  im- 
portant, because  in  writing  the  patients  are  by  themselves  and  are 
more  free  in  expression.  A  skilfully  dissimulating  paranoiac  used  to 
confide  his  delusions  only  on  toilet  paper;  and  as  his  wife,  who 
suffered  severely  in  consequence  of  his  disease,  collected  these  docu- 
ments she  obtained  the  necessary  material  for  divorce  and  guardianship. 


CHAPTER  m 

PHYSICAL  SYMPTOMS 

Among  the  physical  symptoms  those  of  a  neurological  nature  are 
especially  important,  because  on  the  one  hand  many  psychoses  are 
partial  manifestations  of  an  organic  affection  of  the  central  nervous 
system,  and  on  the  other  hand  the  functional  neuroses  are  mental  dis- 
eases. Although  it  is  a  matter  for  the  neurological  clinic  to  deal  with 
the  semeiology,  we  shall  mention  here  some  of  the  most  important 
symptoms  for  orientation. 

Paralyses  occur  in  the  organic  brain  diseases,  especially  in  idiocy, 
paresis,  and  in  Korsakoff's  disease.  In  the  latter  case  paralyses  are, 
of  course,  mostly  peripheral.  Psychic  paralyses  occur  less  frequently 
and  are  of  hysterical  genesis,  even  if  found  in  cases  other  than  hysteria. 
Many  paralyses  result  in  contractures.  There  are  aleo  primary 
(hysterical)  contractures. 

Real  convulsions  occur  in  epileptiform,  paretic,  catatonic,  and  hys- 
terical attacks.  Huntington's  disease  is  always  accompanied  by 
choreic  movements.  In  ordinary  chorea  the  psychic  disturbances  some- 
times rise  to  the  height  of  a  psychosis.  The  slow  athetoid  movements 
which  ordinarily  confine  themselves  to  a  limb  or  to  half  of  the  body 
are  manifestations  of  brain  lesions  in  postencephalitic  idiocies  or 
apoplectic  dementia,  and  other  similar  cases.  Other  convulsive  mani- 
festations are  chewing  motions  and  grinding  of  teeth  in  idiots,  in 
organic  patients,  and  in  acute  delirium.  The  European  sleeping  sick- 
ness (Encephalitis  lethargica)  shows  all  sorts  of  hyperkinesias,  par- 
ticularly a  stiffness  of  the  muscles  of  mimicry  which  is  not  the  same 
as  the  schizophrenic  "rigidity"  but  as  it  is  often  associated  with  in- 
difference and  lack  of  energy,  it  cannot  in  itself  be  differentiated  from 
schizophrenia. 

Disturbances  of  coordination  of  a  very  definite  form  belong  to 
the  picture  of  paralysis,  while  bad  coordination  of  motion  in  general, 
to  the  middle  and  higher  grades  of  oligophrenias. 

Tremors  very  frequently  accompany  the  psychoses.  Thus  we  have 
the  fine,  even  tremor  in  uncomplicated  chronic  alcoholism  and  in  some 
cases  of  schizophrenia,  the  various  kinds  of  coarse  tremors  in  all 
organic  diseases,  such  as  the  severe  forms  of  alcoholism  and  delirium 

157 


158  TEXTBOOK  OF  PSYCHIATRY 

tremens,  the  febrile  toxaemias  and  some  cases  of  exhaustion.  A  form 
of  organic  tremor  is  especially  seen  in  simple  senile  dementia  and  quite 
regularly  accompanies  this  disease.  Irregular  tremors  are  often  only 
a  sign  of  some  form  of  excitement. 

With  the  exception  of  the  Babinski,  the  cutaneous  reflexes  are 
practically  of  no  significance  in  psychiatry.  More  important  are  the 
tendon  or  deep  reflexes,  the  latter  are  increased  wherever  control 
by  the  cerebrum  is  disturbed,  as  in  idiocy,  in  hysteria,  also  in  dementia 
prsecox;  this  phenomenon  is  naturally  most  pronounced  in  the  organic 
psychoses.  The  crossing  over  of  the  patellar-reflex  to  the  other  leg 
most  frequently  to  the  adductors  (contra-lateral  movement),  if  the 
reflex  can  be  elicited  through  the  tibia  or  patella,  indicates  with  rea- 
sonable probability  an  organic  disturbance.  Through  affections  of 
the  peripheral  nerve  and  the  cord  the  exaggeration  can  be  overcom- 
pensated  even  to  the  total  disappearance  of  the  reflexes  (Alcoholic 
Korsakoff,  tabo-paresis) . 

In  the  diagnosis  of  hysteria  some  people  attach  import,ance  to  the 
absence  of  the  pharyngeal-reflex.  This  reflex  is  also  absent  in  bromism 
and  in  many  normal  persons,  depending  entirely  on  the  examination. 

The  disturbances  of  the  pupilary-reflexes  depend  on  the  organic 
affection.  In  paresis,  one  usually  finds  rigidity  to  light  (Argyll- 
Robertson's  phenomenon),  but  it  is  also  an  important  sign  of  other 
syphilitic  affection  of  the  nervous  system;  it  may  also  occur  transi- 
ently in  organic  forms  of  alcoholism  and  also  in  sleeping  sickness. 
Catatonia  seems  to  favor  functional  pupilary  disturbances  which  are 
as  yet  incomprehensible. 

Anesthesias  and  analgesias  have  already  been  mentioned,  also 
hyperesthesias  (p.  55).  Paresthesias  can  have  an  organic  origin  in 
degenerations  of  the  central  or  peripheral  nervous  system,  or  they 
can  be  psychically  determined.  Slight  degenerative  and  toxic  proc- 
esses seem  to  produce  changes  in  the  physical  sensations  in  cases  of 
schizophrenia,  which  in  turn  give  cause  for  hypochondriacal  delusions 
and  interpretations  in  the  form  of  physical  hallucinations. 

The  remaining  physical  functions  are  effected  in  some  cases  by 
the  psychic  alterations  (loss  of  appetite  in  depression),  in  others  they 
are  organically  determined  by  the  underlying  disease,  such  as  paresis, 
and  in  still  others  they  are  the  cause  of  the  psychic  alteration  (Base- 
dow psychoses,  athyroidism,  cases  of  amentia).  The  insomnias  which 
regularly  accompany  the  acute  states  have  very  divergent  connections. 

Menstruation  often  stays  away  for  some  time  in  acute  psychoses; 
at  least  the  subjective  sensations  of  menstruation  such  as  pain,  etc.,  are 
very  uncommon  in  chronic  diseases  where  the  patients  no  longer  think 


PHYSICAL  SYMPTOMS  159 

of  the  function  this  is  particularly  the  case  in  schizophrenia.  In  cases 
of  debility  where,  on  the  contrary,  such  things  are  very  important,  one 
finds  many  menstrual  difficulties.  Childbirth  proceeds  very  smoothly 
when  the  disease  absorbs  the  patient  to  such  an  extent  that  the 
physiological  act  is  not  disturbed  by  the  psyche.  This  shows  that 
it  is  essentially  the  interference  of  the  psyche  which  makes  the  func- 
tion of  childbirth  so  remarkably  burdensome.  Even  women  who  at 
former  confinements  needed  artificial  assistance  are  wont  to  go  through 
easy  births  in  the  psychoses,  unless  serious  anatomical  hindrances  are 
in  the  way.  The  potency  with  the  libido  is  diminished  in  some  de- 
pressions, in  morphinism,  in  many  schizophrenics,  in  the  excited  initial 
stages  of  organic  psychoses,  especially  in  paresis;  but  in  senile  cases 
whose  sexual  impulse  seems  almost  extinguished  the  potency  and 
libido  are  sometimes  increased.  In  chronic  alcoholism,  only  the  libido 
is  enhanced  while  the  potency  is  diminished  in  most  cases. 

At  the  height  of  the  depression  there  is  an  absence  of  tears.  In 
schizophrenia  all  secretions  may  be  disturbed  quite  capriciously  in 
the  most  varied  ways.  In  cases  of  refusal  of  nourishment  and  nat- 
urally also  in  diabetic  psychoses,  one  often  finds  acetone  in  the  urine. 
Metabolism  is  markedly  influenced  in  a  most  incomprehensible  man- 
ner, especially  in  paresis  and  dementia  prsecox  where  one  frequently 
notes  fluctuations  from  extreme  marasmus  to  excessive  obesity  and 
the  reverse.  In  acute  diseases  the  bodily  weight  usually  diminishes, 
and  increases  during  convalescence. 

For  the  rest  one  knows  a  lot  of  details  about  disturbances  of  diges- 
tion, of  metabolism,  and  of  the  blood  picture,  but  as  yet  ver>'  little 
that  is  constant,  that  is  sufficiently  comprehensible,  or  that  would 
contribute  to  the  understanding.  The  temperature  is  normal  in  almost 
all  psychoses,  but  one  also  observes  febrile  attacks,  particularly  in 
paresis,  where  it  is  cerebrally  conditioned,  and  in  hysteria  where  it  is 
psychogenetically  induced.  Subnormal  temperatures  are  sometimes 
encountered  in  marasmic  conditions,  in  cerebral  affections,  and  also 
without  any  explanation  in  schizophrenia. 

The  heart  and  vasomotor  system  remain  uninfluenced  in  no 
psychoses,  except  perhaps  in  paranoia. 

In  paresis,  perhaps  also  in  senile  processes,  and  in  schizophrenia, 
one  sees  tabetic  and  other  rarefications  of  the  bones.  Other  trophic 
disturbances  such  as  the  tendency  to  otohaematoma  and  decubitus 
are  variously  determined  in  organic  diseases. 

With  the  aberration  of  the  cerebral  predisposition  which  is  at  the 
basis  of  many  mental  diseases,  the  physical  development,  too,  merges 
into  false  paths,     A  great  number  of  patients  carry  with  them  manj- 


160  TEXTBOOK  OF  PSYCHIATRY 

malformations,  or  surely  more  than  the  average  of  those  mentally 
normal,  from  a  subnormal  bodily  height,  deformed  skull,  badly  formed 
ears  and  palates,  irregular  position  of  the  teeth  or  insufficiently  de- 
veloped teeth,  to  the  abnormal  length  of  the  vermiform  appendix. 
For  a  long  time  great  stress  was  laid  on  these  "degenerative  signs";  in 
individual  cases  it  is  hardly  permitted  to  draw  any  conclusion  about 
the  psyche  from  either  their  presence  or  absence.  On  the  other  hand, 
they  predominate  as  a  whole  in  oligophrenics,  in  epileptics,  and  crimi- 
nals, and  less  in  other  mental  diseases.  They  have  apparently  some- 
thing to  do  with  injuries  of  the  germ  and  point  to  a  teratologic  origin 
of  the  disease.  The  diseases  which  are  sometimes  described  as  "de- 
generative psychoses,"  namely,  paranoia  and  manic  depressive  insanity 
are  very  frequently  found  in  persons  of  particularly  good  physical 
development. 


CHAPTER  IV 

THE  MANIFESTATIONS  OF  MENTAL  DISEASES 

A  psychosis  is  generally  a  complicated  structure  which  may  mani- 
fest itself  in  very  different  ways,  not  only  from  one  patient  to  another, 
but  in  the  same  patient  at  different  times.  The  manifestations  were 
formerly  taken  for  the  diseases  themselves/  and  even  yet  it  is  of 
practical  value  to  emphasize  them  as  pictures  of  morbid  states  and 
as  syndromes. 

MORBID  STATES 

The  manic  state:  On  the  affective  side  one  observes  an  exalted 
and  very  changeable  mood  which  is  especially  easily  transformed  into 
anger;  in  thought,  there  is  flight  of  ideas,  centrifugal  pressure  activity; 
as  accessory  symptoms  one  not  seldom  sees  overestimated  and 
grandiose  ideas. 

The  expressions  "mania"  now  usually  means  the  manic  state  of 
manic  depressive  insanity.  In  countries  speaking  the  Romance  lan- 
guages or  English  it  still  designates  generally  any  excitement  especially 
when  it  evinces  itself  in  motor  expression. 

When  the  euphoric  excitement  gives  a  feeble  and  stupid  impression, 
some  still  speak  of  it  as  Moria.  Distinct  flight  of  ideas  need  not  be 
present,  Moria  occurs  especially  when  manic  attacks  are  subsiding, 
and  in  lesions  of  the  frontal  lobe.  To  be  sure,  exalted  moods  in  de- 
menting psychoses  of  any  kind  frequently  also  manifest  a  similar 
appearance. 

Depression  or  Melancholic  states  with  a  painful  accentuation  of 
all  experiences,  retardation  of  thought  and  of  the  centrifugal  functions. 
As  accessory  symptoms:  depressive  delusions. 

The  expression  "Melancholia"  designated  for  a  long  time  the  form 

of  melancholia  of  the  "involutional  period,"  especially  emphasized  by 

Kraepelin,  and  is  now  also  used  to  designate  the  depression  of  manic 

depressive  insanity  by  those  who  have  fused  the  two  morbid  pictures 

into  one. 

^  Kahlbaum  deserves  the  credit  for  having  made  a  deliberate  and  sharp  dif- 
ferentiation between  "conditions"  and  '"diseases,"  even  though  in  his  time  the 
position  of  science  had  not  yet  made  it  possible  to  circumscribe  natural  morbid 
pictures  more  exactly. 

161 


162  TEXTBOOK  OF  PSYCHIATRY 

The  manic  and  the  melancholic  (depressive)  states  we  see  almost 
in  pure  form  in  the  common  cases  of  manic  depressive  insanity,  also 
accidentally  more  or  less  frequently  in  most  other  mental  diseases. 

Delusional  insanity  refers  to  acute  conditions  in  which  delusions 
and  hallucinations  or  even  only  one  of  the  two  symptoms  dominate 
the  picture  to  such  an  extent  that  the  patient  loses  his  pose,  and 
frequently  also  his  orientation. 

The  expression  is  now  rarely  applied  to  chronic  conditions.  When 
a  distinct  emotional  fluctuation  is  combined  with  it,  or,  what  is  usually 
the  same  thing,  when  one  deals  with  an  onset  of  manic  depressive 
insanity,  one  also  speaks  of  manic  or  melancholic  insanity. 

What  for  a  time  was  called  delusional  insanity  ("Wahnsinn")  were 
mostly  hallucinatory  excitements  of  schizophrenia.  We  still  use  the 
name  only  for  the  forms  of  manic  depressive  onsets,  which  cannot  be 
otherwise  classified,  in  which  hallucinations  and  illusions  more  or  less 
conceal  the  fundamental  complex;  we  use  it  at  times  for  similar  schizo- 
phrenic pictures. 

Meynert  once  believed  that  under  this  name  ("Wahnsinn")  he 
described  a  particular  disease.  He  later  substituted  for  it  the  term 
amentia. 

The  term  Confusion  is  ambiguous;  in  the  first  place  it  designates 
the  thought  disturbances  described  above  ^  that  have  no  limits  as  to 
incoherence  and  dissociation.  But  more  complicated  conditions  of 
very  different  origin  are  also  designated  in  this  way,  being  conceived 
at  times  as  syndromes,  at  times  as  pictures  of  conditions  and  at  times 
as  diseases.  According  to  Ziehen,  confusion  is  a  symptom  complex, 
consisting  of  disorientation,  incoherence  of  the  course  of  ideation  and 
motor  incoherence.  The  ''diseases"  designated  as  confusion  corre- 
sponded approximately  to  the  newer  amentia  of  average  degree. 
Here  we  use  the  expression  only  for  the  above  named  mental 
disturbances. 

"Hallucinatory  Confusion"  is  symptomologically  about  the  same 
as  the  broader  amentia ;  therefore,  what  is  still  so  called  belongs  nearly 
altogether,  in  part  to  our  amentia,  and  in  part  to  schizophrenia. 

Only  conditions  that  last  for  a  long  time  and  that  are  conceived  as 
an  entire  disease  are  called  amentia.  Like  confusion,  it  cannot  be 
sharply  defined  symptomatically  from  twilight  states  and  the  deliria,^ 
concepts,  that  we  cannot  as  yet  dispense  with  entirely.  Transient  con- 
fusion, twilight  states  and  deliria,  be  they  pronounced  or  merely  indi- 
cated, we  called  "clouded  states." 

'Cf.  p.  86. 
='Cf.  p.  HI. 


THE  MANIFESTATIONS  OF  MENTAL  DISEASES       1G3 

Acute  delirium  is  now  a  rare  brain  disease.  It  is  evidently  based 
on  different  infections  or  on  schizoplirenio  processes,  and  shows  itself 
in  deliria,  convulsive  manifestations,  and  in  most  cases  in  a  rapidly 
ending  death. 

Hallucinosis  is  Wernicke's  designation  for  acute  hallucinatory  con- 
ditions in  which,  in  contrast  with  the  deliria  and  the  greater  part  of 
the  twilight  states,  orientation  and,  in  part,  clearness,  are  retained 
(alcoholic  hallucinosis). 

Dreamy  state  is  nothing  but  another  name  for  twilight  state. 

Transitory  psychoses  *  are  attacks  which  appear  and  disappear 
suddenly,  with  disturbances  of  consciousness  of  brief  duration.  They 
occur  in  the  manifold  psychopathic  states  (Magnan's  boufTees 
delirantes)  with  or  without  affective  or  toxic  cause,  then  too,  in  latent 
and  manifest  forms  of  real  psychoses,  especially  in  schizophrenia  and 
epilepsy.  Many  may  be  included  in  the  concepts  of  twilight  states. 
At  times  they  are  the  cause  of  crimes. 

Stupor  '^  is  a  state  of  various  origins  that  occurs  especially  in 
schizophrenia,  then  in  hysteria,  epilepsy  and  also  in  auto-intoxication, 
etc.,  rarely  in  manic  depressive  insanity.  Emotional  stupor  is  a  syn- 
drome seen  in  different  conditions,  especially  in  the  different  kinds  of 
"nervosities,"  in  the  widest  sense,  and  in  the  oligophrenias. 

Stuporous  forms  with  almost  complete  immotility  are  designated  as 
Attonity.  This  is  usually  a  catatonic  condition;  but  a  melancholia 
attonita  has  also  been  distinguished;  whether  the  latter  exists,  i.e., 
whether  the  retardation  of  merely  depressive  conditions  may  rise  to  a 
continuous  immotility,  is  questionable. 

Under  cloudiness  we  understand  different  conditions  of  narrowed, 
unclear,  slowly  performed  thinking,  in  which  stimuli  are  lacking  or 
at  any  rate  merge  into  the  background.  Such  conditions  are  seen  in 
slumber,  in  fever,  in  epilepsy,  in  schizophrenia,  and  in  organic  states 
of  all  kinds.  A  part  of  these  pictures  naturally  may  just  as  well  be 
called  stupor. 

The  picture  of  the  condition  of  hypochondria  consists  in  continuous 
attention  to  one's  own  state  of  health  with  the  tendency  to  ascribe  a 
disease  to  oneself  from  insignificant  signs  or  also  without  such.  It 
occurs  in  dementia  praecox,  in  depressive  and  neurasthenic  conditions, 
in  initial  stages  of  organic  psychoses  (arteriosclerosis,  paresis),  and 
in  psychopathic  states  of  all  kinds.  AVe  no  longer  recognize  hypo- 
chondria as  a  disease. 

Catatonia  as  such  is  a  manifestation  of  schizophrenia.    But  cata- 

*  Formerly  in  their  excited  forms  also  called  transitory  manias. 
"Cf.  pp.  143-144. 


164  TEXTBOOK  OF  PSYCHIATRY 

tonic  symptoms  also  occur  in  organic  mental  diseases,  in  epilepsy  and 
in  fever  psychoses. 

Paranoid  symptoms  is  the  designation  for  hallucinations  and  de- 
lusions when  they  appear  in  a  state  of  mental  clearness  and  without 
(primary)  fluctuations  of  the  affects. 

"Acute  (hallucinatory)  Paranoia"  was  conceived  by  Ziehen  and 
others  as  a  disease.  The  majority  of  these  so  called  conditions  belongs, 
in  our  opinion,  to  the  acute  manifestations  of  schizophrenia. 

Religious  mania,  or  mania  religiosa,  is  any  mental  disease  with 
religious  delusions;  it  is  thus  mainly  a  question  of  dementia  prsecox. 
Nevertheless  some  observers  still  designate  a  melancholia  with  pro- 
nounced delusions  of  sin  as  religious  mania. 

Dementia  (feeble  mindedness)  is  not  a  uniform  condition.  One 
deals  here  with  a  purely  practical  conception.  Whoever  fails  in  life 
because  of  intellectual  insufficiency  is  demented.  In  a  scientific  sense 
there  is  no  uniform  dementia,  but  only  an  oligophrenic,  epileptic, 
organic  dementia,  i.e.,  forms  which  in  their  entire  character  are  very 
different  from  one  another.  The  diagnosis  "dementia"  is  scientifically 
never  sufiicient;  one  can  diagnose  only  a  particular  kind  of  dementia. 

As  psychopathies  we  designate  the  mass  of  congenital  or  at  any 
rate  permanent  psj^chic  deviations  from  the  normal  which  have  not 
yet  been  included  into  any  other  class,  and  which  exist  chiefly  in  the 
borderline  between  health  and  disease.  Among  these  one  naturally 
finds  many  undeveloped  real  mental  diseases,  especially  latent  schizo- 
phrenia. Many  believe  that  they  connect  a  well  defined  conception 
with  this  expression,  but  they  are  certainly  mistaken. 

Degeneration.^  "Degenerates"  are  usually  about  the  same  type  as 
psychopathies,  namely,  individuals  who  intellectually  and  especially 
affectively  react  differently  from  the  average.  "Degeneres  superieurs" 
(superior  degenerates)  are  psychopaths  who  stand  above  the  average 
in  some  line  and  can  maintain  themselves  in  the  world.  It  is  only 
just  to  state  that  famous  men  belong  to  this  class.'' 

SYNDROMES 

Syndromes  are  complexes  of  symptoms  that  belong  together 
genetically.  A  part  of  such  pictures  as  manic  depressive  insanity, 
eventually  with  their  corresponding  delusions,  represent  at  the  same 
time  such  syndromes.  One  speaks,  furthermore,  of  an  "organic  symp- 
tom complex,"  also  called  the  Korsakoff  syndrome  and  understands  by 

'Cf.  p.  201. 

'  For  some  etiological  designations  see  end  of  the  chapter  on  Causation. 


THE  MANIFESTATIONS  OF  MENTAL  DISEASES       165 

this  term  the  sum  of  the  psychical  fundamental  symptoms  of  a  diffuse 
atrophy  of  the  cortex,  or  of  a  general  lowering  of  the  function  of 
the  cortex  through  shock  or  injury  of  the  brain.* 

The  Katathymic  delusional  formation,  i.e.,  a  delusional  formation 
with  clearness  in  other  respects,  which  is  not  due  to  a  general  moodi- 
ness but  to  a  definite  "complex,"  or  a  particular  experience,  is  a  syn- 
drome in  itself.  It  alone  or  combined  with  hallucinations  forms  the 
paranoid  syndrome,  which  is  to  be  distinguished  from  the  paranoid 
constitution.  The  latter  type  of  personality  readily  refers  the  actions 
of  others  to  himself,  or  interprets  them  in  the  sense  of  a  definite  atti- 
tude (suspicion,  persecution,  grandeur)  without  progressing  to  the  dis- 
tinct formation  of  a  real  delusion.  We  can  also  mention  here  the 
hysterical  and  neurasthenic  symptom  complex,'^  the  compulsive  symp- 
toms, the  anxiety  psychosis  and  anxiety  neurosis,  also  the  fright  neu- 
rosis, the  expectation  neurosis  and  the  twilight  states,  because  they 
are  all  produced  by  definite  mechanisms  on  different  foundations  such 
as  the  psychopathic,  hysteric,  and  epileptic.  Under  the  twilight  states 
several  types  are  to  be  distinguished,  which  permit  of  fairly  good 
differentiation  on  the  basis  of  their  psychic  genesis:  thus  we  have  the 
Ganser  Syndrome,  which  represents  a  "mental  disease,"  in  the  form 
of  acting  and  thinking  in  a  manner  which  is  the  reverse  of  the  normal; 
the  buffoonery  syndrome  in  which  the  patient  plays  the  fool  in  the 
"vulgar"  sense;  ^^  puerilism,"  when  the  patient  behaves  like  a  little 
child  and  the  pseudo-dementia  in  which  the  patient  "knows  nothing." 
Moreover,  wishes  are  not  only  realized  through  the  twilight  states  but 
also  hallucinatorily  in  the  twilight  states,  inasmuch  as  the  patients 
dream  themselves  into  the  desired  situation.  The  wish  to  be  insane 
and  to  appear  irresponsible  is  fulfilled  through  the  Ganser  state  which 
is  a  mental  disease,  or  the  wish  to  be  innocent  and  pardoned  is  realized 
in  the  prison  delirium  which  dehides  the  patients  with  the  fact  that 
they  are  innocent  or  forgiven.  The  maximum  of  wish  fulfilment  is 
achieved  by  the  ecstasies.^-  These  syndromes  are  also  called  Purpose 
psychoses. 

Among  the  twilight  states  the  wandering  mania  (poriomania, 
fugues)  deserves  special  consideration.  It  manifests  itself  in  a  run- 
ning away  that  is  completely  aimless,  or  dominated  by  a  single  con- 
fused and  uncontrollable  idea;  at  times  it  is  merely  motor  without 

''Cf.  p.  230. 

*  For  the  kinds  of  manifestations  see  the  corresponding  diseases. 
^"As  in  spoiled  children,  the  buffoonery  observed  in  schizophrenia  may  excep- 
tionally be  used  as  a  means  to  hide  the  despair. 
"  Not  to  be  confused  with  infantilism. 
"Cf.  p.  113. 


166  TEXTBOOK  OF  PSYCHIATRY 

any  consideration  for  the  outer  world  except  what  is  necessary  for 
running;  at  times  it  is  externally  inconspicuous,  the  act  seems  planned 
with  correct  use  of  transportation  and  with  the  possibility  of  contact 
with  other  people;  at  other  times  it  is  done  in  a  way  that  it  can  be 
placed  between  these  two  extremes.  The  milder  forms  are  rather 
psychogenic  and  may  therefore  occur  everywhere,  even  in  hysterics  and 
ordinary  psychopaths,  especially  in  those  who  are  young,  as  a  result 
of  an  exciting  experience,  a  temptation,  or  an  unbearable  situation. 
The  severer  forms  belong  chiefly  to  epilepsy,  while  those  who  are  mid- 
way between  the  two  classes  belong  in  the  main  to  schizophrenia. 

Querulousness  is  generated  by  an  exalted  self-consciousness  where 
there  is  activity  and  lack  of  understanding  for  the  rights  of  others ;  this 
occurs  in  schizophrenia,  paranoia,  manic  depressions  of  long  duration, 
traumatic  neurosis,  and  prison  confinements.  Aside  from  the  affective 
explosions  of  rage  (prison  outburst),  confinement  produces  conditions 
in  which  on  the  one  hand  the  patient  imagines  himself  pardoned, 
acquitted,  or  innocent,  on  the  other  hand  persecuted  by  those  about 
him.  Syndromes  that  are  put  in  motion  by  a  definite  situation,  as 
prison  psychoses,  Ganser,  etc.,  transitory  affect  psychoses,  and  even- 
tually also  querulousness,  are  also  comprehended  under  the  name  of 
situation  psychoses. 

Further  syndromes  are  "attacks,"  such  as  the  epileptiform  in  the 
narrower  sense  with  petit  mal,  Jacksonian  epilepsy,  paretic,  and  cata- 
tonic attacks. 

Hoche  wanted  to  supplant  the  pictures  of  diseases  that  are  still 
too  fluctuating  by  the  theory  of  the  syndrome,  urging  that  one  should 
be  satisfied  with  a  diagnosis  of  the  latter.  But  even  the  syndrome 
theory  is  by  no  means  complete;  the  identical  syndrome  has  an  en- 
tirely different  significance  for  therapy  and  especially  for  practice, 
according  to  whether  it  occurs  in  an  hysteria,  or  epilepsy,  or  schizo- 
phrenia; besides  we  now  know  altogether  too  much  about  the  "dis- 
eases" in  the  ordinary  sense  to  be  able  to  disregard  these  conceptions 
without  a  severe  loss  to  science.  On  the  other  hand,  it  would  be  an 
advantage  to  carry  out  a  syndromistic  treatment  of  those  symptom 
complexes  that  are  only  deviations  from  the  normal  average  either  in 
predisposition,  as  in  psychopathic  conditions,  or  in  reaction  as  in  neu- 
roses, purpose  and  situation  psychoses,  and  paranoias. 


CHAPTER  V 

THE  COURSE  OF  MENTAL  DISEASES 

Few  generalizations  can  be  made  concerning  the  course  of  mental 
diseases.  The  congenital  mental  diseases  run  a  "course"  only  to  tlie 
extent  that  at  times  they  show  acute  syndromes  or  sometimes  progress 
as  in  puberty,  or  that  they  combine  with  a  new  disease  such  as  epilepsy, 
schizophrenia,  alcoholism,  or  atrophy  of  the  brain. 

In  acquired  psychoses  one  frequently  speaks  of  prodromal  stages, 
but  here  as  in  most  cases  they  represent  nothing  but  such  mild  morbid 
symptoms,  that  a  diagnosis  is  impossible.  The  most  frequent  of  these 
are:  depression,  exaltation,  eccentricities,  nervous  symptoms  or 
changes  of  character,  in  which  the  new  attitude  may  resemble  the 
character  of  many  healthy  people,  and  in  itself,  therefore,  does  not 
necessarily  seem  morbid.  To  be  sure,  all  the  real  signs  of  mental  dis- 
eases in  a  less  marked  form  may  also  have  the  significance  of 
prodromes. 

The  "beginning  of  the  actual  disease"  is  usually  furtive  if  one  does 
not  designate  acute  episodes  in  chronic  pictures  as  "the"  disease,  as 
frequently  used  to  happen  and  even  now  occurs  in  the  onsets  of  manic 
depressive  insanity.  At  all  events  certain  deliria,  hysterical  twilight 
states,  and  similar  processes  are  in  the  real  sense  acute. 

The  entire  course  is  mostly  chronic,  even  in  the  sense  of  psychiatry, 
which  also  designates  as  acute  diseases  depressions  extending  over  a 
period  of  years,  provided  they  regain  normal  balance.  Here  the  term 
"acute"  has  come  to  mean  approximately  something  transitory-  while 
the  term  "chronic"  something  incurable.  In  organic  psychoses,  which 
after  a  long  while  end  in  death,  one  usually  avoids  the  division  of 
acute  and  chronic,  as  far  as  the  disease  is  concerned. 

During  the  course  one  encounters  acute  shifts,  acute  onsets,  exacer- 
bations and  remissions.  Shifts  are  rapidly  appearing  aggravations  of 
the  disease;  the  concept  usually  indicates  that  the  given  aggravation 
does  not  usually  equalize  itself.  Shifts  are  often  connected  with  some 
form  of  excitement  and  other  accessory  symptoms,  which  except  for 
the  given  lasting  injury  may  recede  to  former  states.  Paresis  and 
schizophrenia   are  usually   first  recognized  as   diseases   during   such 

167 


168  TEXTBOOK  OF  PSYCHIATRY 

"shifts"  after  they  have  furtively  transformed  the  patient  for  some 
time.  In  dementia  praecox  many  of  these  shifts  assume  the  form  of 
schizophrenic  manias  and  melancholias,  of  catatonias,  and  other  syn- 
dromes that  were  formerly  considered  special  psychoses.  Exacerba- 
tions are  aggravations  in  general,  especially  such  as  readjust  them- 
selves. Among  them  one  observes  many  psychically  determined 
excitements,  or  twilight  states  (e.g.  in  schizophrenia),  that  are  not 
directly  connected  with  the  process  of  the  disease,  but  are  only  transient 
reactions  of  the  diseased  psyche  to  certain  stimuli.  To  be  sure  they 
generally  disappear,  leaving  no  trace  of  themselves.  The  term,  exacer- 
bation, does  not  usually  designate  the  acute  attacks  that  belong  to 
the  morbid  picture,  such  as  the  moodiness  and  twilight  states  of 
epilepsy  or  the  manias  and  melancholias  of  manic  depressive  insanity. 
All  the  mentioned  transient  states  of  chronic  diseases,  taken  together, 
may  be  designated  as  acute  onsets.  Between  the  aggravations  there 
are  remissions ;  whether  one  may  also  assume  intermissions  in  forms 
like  manic  depressive  insanity  depends  on  the  conception.  With 
Kraepelin,  Magnan  and  others,  we  designate  the  whole  permanent 
state  of  manic  depressive  insanity  as  the  disease,  and  the  acute  appear- 
ances may  also  alternate  with  one  another  in  regular  sequence  so  that 
mania  follows  melancholia  and  the  latter  follows  mania,  etc.,  eventually 
with  normal  intervals  after  the  mania  or  after  the  melancholia  or 
after  both.  Such  formations  are  called  circular  or  cyclic  forms.  Out- 
side of  manic  depressive  insanity  they  occur  occasionally  in  schizo- 
phrenia and  also  in  paresis. 

How  many  insane  patients  are  cured  depends  in  institutional  statis- 
tics very  much  on  the  quality  of  the  cases  received  into  the  hospital, 
otherwise  primarily  on  the  physician's  conception  of  cure.  Whether 
a  schizophrenic  patient  who  is  perfectly  competent  socially,  and  in 
whom  some  remnants  of  the  disease  can  only  be  demonstrated  after 
a  minute  examination,  may  be  considered  as  cured  or  not,  is  a  matter 
of  taste.  I  would  rather  not  call  him  cured,  in  view  of  new  aggrava- 
tions that  usually  appear  later,  such  as  the  question  of  marriage,  and 
similar  consequences,  although  I  am  aware  that  the  disease  may  also 
"definitively  remain  quiescent."  Delirium  tremens,  which  in  hospital 
statistics  often  shows  a  large  percentage  of  cures,  is,  to  be  sure,  as  a 
rule  totally  gone  at  the  discharge,  but  not  the  alcoholism  that  lies  at 
its  basis,  i.e.,  the  disease  is  cured  but  the  patient  is  not.  In  residual 
schizophrenic  states  "cures"  sometimes  take  place  even  many  years 
after  the  patient  has  long  been  given  up;  this  occurs  in  some  without 
any  visible  reason,  in  some  as  a  result  of  a  febrile  disease,  or  a  change 
of  environments,  and  similar  things. 


THE  COURSE  OF  MENTAL  DISEASES  169 

Cure  with  a  defect  is  also  spoken  of  by  formulating  the  concep- 
tion, suitable  only  to  few  cases,  that  the  acute  disease  has  left  a  defect 
just  as  a  healed  wound  leaves  a  scar.  A  "psychic  scar"  may  be  formed 
by  definite  "residual  symptoms,"  as  in  the  case  of  a  delusion  which 
in  spite  of  returned  clearness  following  a  delirium  is  no  longer  cor- 
rected. If  the  psychic  scar  is  so  severe  and  multiform  that  it  may  be 
considered  as  a  disease  in  itself,  the  morbid  picture  was  formerly  desig- 
nated as  secondary  to  distinguish  it  from  the  primary  disease  that 
formed  it  ("secondary  dementia,"  "secondary  paranoia").  The  con- 
ception must  now  be  given  up  as  in  such  cases  it  is  nearly  always  a 
question  of  dementia  pra>cox,  which  does  not  change  its  nature. 

Nearly  all  organic  mental  diseases  and  some  severe  cases  of  other 
forms,  e.g.,  of  catatonia  end  in  death.  Of  the  remaining  a  small  part 
indirectly  ends  fatally  through  suicide,  unhygienic  living,  refusal  of 
nourishment,  exhaustion  from  restlessness  and  insomnia,  injuries,  and 
infection. 

In  making  the  prognosis  we  have  to  differentiate  the  "direction 
prognosis"  and  in  chronic  diseases,  in  addition,  the  "extent  prog- 
nosis." Organic  mental  diseases  run  in  the  direction  of  a  definite 
dementia  and  end  in  death;  the  epileptic  and  schizophrenic  follow  the 
direction  of  other  kinds  of  dementia  and  usually  do  not  end  in  death. 
Within  the  realm  of  schizophrenia  there  are  again  different  directions 
such  as  the  paranoid,  catatonic  dementia,  etc.,  that  have  to  be  con- 
sidered in  the  prognosis.  Not  less  important  is  often  the  "extent 
prognosis,"  i.e.,  the  prediction  how  far  the  disease  will  progress  within 
a  conceivable  period.  Will  the  disease  soon  come  to  a  stop,  or  will 
there  be  some  improvement?  Will  the  patient  become  socially  in- 
competent through  dementia?  Or  will  he  be  able  to  maintain  himself 
in  spite  of  the  disease?  And  under  what  circumstances?  In  dementia 
praecox,  epilepsy  and  the  severe  forms  of  manic  depressive  insanity 
these  questions  must  often  be  put  and  sometimes  their  answer  is  pos- 
sible with  considerable  probability. 


CHAPTER  VI 

THE  BORDERLINES  OF  INSANITY 

Nowhere  is  the  question:  "sick  or  not  sick?"  put  so  often,  in  such  | 
an  inexorable  manner  and  with  such  heavy  consequences  as  in  the 
judgment  of  mental  conditions.  But  the  given  question  is  false.  There 
are  no  borderlines  of  insanity,  no  more  than  for  any  other  disease. 
In  every  person  a  tubercular  bacillus  occasionally  takes  hold;  one  or 
the  other  of  the  microbes  may  even  divide  once  or  twice.  How  many 
bacteria  must  be  present,  how  much  living  tissue  must  have  been  de- 
stroyed before  the  individual  should  be  called  tubercular?  Or  begin- 
ning with  what  degree  of  susceptibility  is  the  ''predisposition  to 
tuberculosis"  morbid?  No  one  will  want  to  answer  such  a  question. 
Still  more  senseless  is  the  question  about  well  and  sick  where  it  is  not 
a  case  of  something  added  but  of  a  plain  deviation  from  the  normal. 
Where  is  the  borderline  between  healthy  stupidity  and  morbid  feeble- 
mindedness? Where  is  the  boundary  between  normal  and  supernormal 
size  of  body?  If  the  boundary  line  is  lacking  here,  then  there  are 
extensive  fields  in  which  the  conceptions  "sick"  and  "healthy"  are  not 
at  all  applicable,  as  little  as  the  various  shades  of  light  in  a  photograph 
can  be  divided  into  black  and  white;  most  of  them  are  gray  as  a 
matter  of  fact. 

That  the  people  and  jurisprudence  repeatedly  demand  an  answer 
to  such  senseless  questions  from  the  psychiatrist  is  due  to  the  conse- 
quences. They  really  do  not  want  to  know  whether  a  person  is 
healthy  or  sick,  but  they  want  to  know  whether  he  is  to  be  taken 
seriously,  whether  he  is  to  be  committed  to  a  hospital,  whether  he 
is  responsible  and  capable  of  acting,  etc.,  and  all  that  they  want  to 
infer  from  the  confirmation  "sick  or  not  sick?"  This  method  of  infer- 
ence is  in  itself  wrong,  not  only  because  in  a  very  wide  zone  the  con- 
ceptions sane  and  insane  cannot  be  applied  at  all,  but  also  because 
there  are  patients  that  need  not  be  committed,  that  may  have  good 
ideas,  that  are  not  incapacitated,  that  are  not  irresponsible.  Today 
Schizophrenia  and  paresis  may  frequently  be  diagnosed  before  one 
would  care  to  act  upon  the  social  consequences  of  such  a  confirmation, 
and  with  the  refinement  of  our  diagnostic  resources  such  cases  will 
always  increase.    On  the  other  hand,  under  certain  circumstances  a 

170 


THE  BORDERLINES  OF  INSANITY  171 

psychopath,  who  is  not  insane,  may  for  a  definite  period  have  lost  his 
ability  to  reflect,  to  such  an  extent,  that  he  is  neither  responsible  nor 
capable  of  action.  And  one  will  often  have  to  decide  within  the 
border  zone  according  to  external  circumstances,  since  the  same  degree 
of  feeblemindedness,  that  does  not  harm  the  day  laborer,  at  all,  in- 
capacitates the  man  who  has  inherited  a  large  business. 

The  whole  difficulty  lies  in  the  fact  that  there  is  no  definition  of 
"disease"  and  there  cannot  be  any.  The  fruitless  controversies  can 
only  cease  when  the  ambiguous  and  indefinite  concept  is  entirely  ex- 
cluded. It  is  easy  enough  to  examine  how  a  person  is  and  reacts,  and 
draw  conclusions  from  the  facts,  instead  of  from  a  concept,  and  then 
determine  our  actions  accordingly. 

Where  chapters  of  the  code  contain_more_deiail£d_jde£.ciiptions  of 
the  concept_jif_-disease, '  theyVary  greatly  according  to  the  conte? 

as  the  concept  of  insanity  has  become  at  all  practical,  it  rests 
not  on  medical  or  psychopathological  criteria,  but  on  the  idea  of  social 
inca;mcity.  That  is  why,  from  practical  points  of  view,  the  neuroses 
whichRrfTprrTrly  piiyrJxic  dist^nses,  arp  nnt^jnohiHpd  inJ-nnnnity^  wVifrr 
they  do  not  lead  to  severe  syndromes  like  clouded  states.  All  the  more 
they  belong  to  theoretical  psychiatry  because  they  are  comprehensible 
only  psychopathologically  and  have  to  be  accurately  known  to  differ- 
entiate them  from  the  other  mental  diseases.  But  much  more  severe 
mental  disturbances,  as  those  in  coarse  brain  diseases  and  in  infections, 
are  usually  not  classed  with  the  psychoses.  From  a  medical  point  of 
view  the  basic  disease  is  taken  as  the  only  thing  important;  socially, 
these  disturbances  have  no  significance  especially  because  of  their 
brief  duration,  unless  an  important  legal  transaction  happens  at  this 
time. 

Hence  we  shall  use  the  expressions  sane  and  insane  only  in  very 
pronounced  cases  and  otherwise,  in  so  far  as  we  are  compelled  to.  At 
the  same  time,  in  the  aberrations  like  mental  debility,  or  psychopathy, 
we  shall  take  the  capacity  required  under  the  given  conditioiis  as  a. 
criterion  to  determine  the  boundary  of  disease.  But  as  soon  as  an 
acquired  disease  is  definitely  proven,  even  though  by  few  and  rela- 
tively mild  symptoms,  we  shall  speak  of  "disease  in  the  medical  sense'' 
and  shall  then  have  to  put  the  questions,  whether  any  conclusions  and 
which  ones  are  to  be  drawn  from  this  finding  after  a  consideration  of 
all  the  circumstances. 

A  question  which  touches  many  people  deeply  is  this,  "Whether 
genius  is  a  disease  or  not?"  Lombroso  asserted  that  it  was  a  disease, 
while  others  have  indignantly  rejected  this  view.  Now  here,  too,  we  do 
not  know  all  we  should  like  to  know.    But  matters  stand  about  like 


172  TEXTBOOK  OF  PSYCHIATRY 

this:  1.  Genius  is  an  aberration  like  any  other;  that  it  is  much  less 
common  than  undesirable  deviations  is  self-evident,  because  few  defects 
in  disposition  can  make  a  man  useless.  One  only  becomes  a  genius 
when  a  large  number  of  attributes  are  simultaneously  very  highly  de- 
veloped. Genius  may  therefore  run  just  as  little  true  to  strain  as  a 
particularly  fine  variety  of  peach  which  as  a  single  aberration  was 
accidentally  cultivated  by  the  gardener.  2.  The  tendency  to  aberration 
usually  involves  the  entire  organism.  Every  domestic  animal  and  every 
plant,  which  can  be  cultivated  along  a  definite  characteristic,  deviates 
more  readily  in  another  direction.  Those  who  are  psychically  abnor- 
mal have  (in  the  average)  many  physical  "stigmata  of  degeneration" 
and  those  who  are  physically  abnormal  have  (in  the  average)  many 
psychic  defects.  In  the  aberration  of  genius  we  therefore,  as  a  rule,  also 
find  relatively  frequently  other  abnormal  qualities,  which  we  must 
usually  give  a  negative  value  (sensitiveness,  nervousness,  etc.).  3.  Be- 
sides, there  is  a  connection  between  genius  and  mental  abnormality: 
The  normal  philistine  is  adjusted  to  the  conditions  in  which  he  was 
born,  and  balances  with  their  little  changes  without  thinking  or  noticing 
much  in  the  process.  The  psychopathic  individual  cannot  adapt  him- 
self so  well,  or  not  at  all;  he  reacts  to  difficulties  resulting  therefrom 
either  by  evasion, — he  may  take  refuge  from  the  demands,  in  hysteria 
or  neurasthenia, — or  he  may  create  an  imaginary  world  for  himself 
through  grandiose  and  persecutory  delusion, — or  aggressively  by  at- 
tempts to  adapt  the  external  world  to  his  necessities,  or  by  both  to- 
gether. Whoever  would  like  the  outer  world  different  in  large  or 
small  matters  is  compelled  to  ponder  over  it  and  strive  for  inventions, 
social  betterments,  etc.  If  he  is  also  sufficiently  intelligent,  the  facility 
of  avoiding  the  usual  paths  may  be  directly  conducive  to  finding  some- 
thing new.  Often  the  lack  of  adaptability  lies  rather  in  inner  diffi- 
culties, because  the  different  tendencies  do  not  equalize  themselves 
but  lead  to  a  lasting  inner  schism.  Such  people  may  combine  the 
contrasts  in  dereistic  thinking  or  obtain  satisfaction  from  without; 
if  they  have  the  other  necessary  qualifications,  they  become  poets  or 
artists.  It  is,  therefore,  not  chance  that  famous  men  are  so  frequently 
the  offspring  of  unlike  parents,  whose  tendencies  do  not  fuse  into  a 
unified  whole  in  the  psyche  of  their  descendants,  but  throughout  their 
lives  strive  in  different  directions.  Poets  and  musicians  must  also  be 
more  sensitive  than  other  people,  a  quality  which  is  a  hindrance  to 
the  daily  tasks  of  life  and  often  attains  the  significance  of  a  disease. 


CHAPTER  Vn 

CLASSIFICATION  OF  MENTAL  DISEASES 

One  class  of  the  psychoses  shows  itself  as  a  morbid  reaction  to  an 
affective  experience,  as  a  prison  psychosis  to  a  confinement,  and  an 
hysterical  twilight  state  to  a  jilting  on  the  part  of  the  beloved  {reactive 
psychoses,  situation  psychoses) .  In  the  other  class  there  is  a  morbid 
process  in  the  brain,  that  conditions  the  psychosis  (process  pychosis, 
progressive  psychosis) }  But  no  division  can  be  based  on  these  classes 
because  the  two  symptomologies  intermingle. 

The  terms  "organic"  -  and  "psychogenic"  indicate  similar  differ- 
ences. With  the  organic  one  naturally  also  classed  the  toxic  psychoses 
resulting  from  changes  of  metabolism,  hormones,  and  from  infections 
and  poisoning  in  the  narrower  sense.  The  idea  of  the  Psychogenic  is 
not  clear  to  many.  It  is  said  that  psychogenic  manifestations,  too, 
must  "naturally"  have  an  anatomical  substratum;  indeed,  an  anatom- 
ical change  has  even  been  postulated  for  things  like  hysterical  paralysis 
of  the  arm.  That  is  wrong.  An  hysterical  paralysis  as  such  has  only 
substrata,  which  in  themselves  are  not  pathologic;  but  as  the  founda- 
tion of  the  hysterical  disposition  there  is  a  nervous  system  anatomically 
• — chemically  somehow  differently  formed  from  that  of  the  normal  dis- 
position. In  a  house  there  are  doors  and  windows  so  that  at  times 
they  may  be  opened,  at  other  times  closed.  If  they  are  open  or 
closed,  it  is  in  itself  no  derangement  of  the  structure;  but  if  they  close 
or  open  too  slowly  or  too  easily,  or  if  there  is  a  rogue  who  brings  it 
about  that  they  move  too  slowly  or  too  easily,  or  who  breaks  them 
or  opens  them  when  they  should  be  closed,  and  closes  them  when  they 
should  be  opened,  those  are  changes  that  may  be  compared  with  the 
anatomical. 

Endogenous  and  exogenous  psychoses  cannot  be  sharply  differ- 
entiated, not  only  because  the  two  factors  mingle  or  combine  in  their 
effects  but  because  the  two  concepts  in  themselves  have  no  definite 

^  For  details  see  Jaspers,  Schicksal  imd  Psychose  bei  der  Dementia  PrEecox, 
Ztschr.  f.  d.  ges.  Neur.  u.  Psych.  Orig.  XIV.  S.  158. 

*The  word  "organic"  designates  here  a  much  broader  conception  than  in  the 
expression  "organic  psychoses"  which — in  order  not  to  have  to  coin  a  new 
name — I  use  for  those  psychoses  that  are  based  on  a  diflferent  reduction  of 
brain  elements. 

173 


174  TEXTBOOK  OF  PSYCHIATRY 

limits.  Idiocy,  whether  stationary  or  progressive,  may  be  endogenous 
in  relation  to  the  patient  but  may  be  the  result  of  an  exogenous  influ- 
ence on  a  parent.  If  schizophrenias  are  based  on  autointoxications, 
they  are  exogenous  in  relation  to  the  brain  but  endogenous  in  relation 
to  the  body.  Nevertheless  Bonhoeffer's  investigations  of  the  exoge- 
nous reaction  types  in  toxic  states  and  infections  have  been  very 
enlightening. 

The  attempt  has  also  been  made  to  classify  on  the  basis  of  causes; 
for  example,  alcoholic,  infections,  and  traumatic  psychoses  have  been 
differentiated.  But  this  principle  cannot  be  carried  out  because  some 
causes  produce  very  different  morbid  pictures,  as  syphilitic  paranoid 
states  and  paresis,  alcoholic  insanity  and  alcoholic  Korsakoff's  dis- 
ease. And  conversely,  the  same  morbid  pictures  might  be  produced 
by  different  causes,  thus  Korsakoff's  diseases  may  be  due  to  alcohol  or 
carbonic  oxide  gas.  That  the  idea  of  causality  is  not  clearly  limited 
need  not  nowadays  be  explained  in  detail. 

Under  Kraepelin's  guidance  the  course  of  diseases  has  been  particu- 
larly emphasized,  thus  the  same  terminal  state  was  supposed  to  be 
proof  that  two  different  groups  (not  diseases)  were  formed  which  are 
entities  even  in  other  respects,  and  will  probably  remain  so  for  us. 
We  refer  to  dementia  prsecox  and  manic  depressive  insanity.  It  is 
nevertheless  impossible  to  base  a  classification  of  morbid  pictures  only 
on  the  course  of  the  disease. 

According  to  a  more  recent  theory  of  these  two  groups  of  psychoses 
one  observes  even  in  normal  people  a  syntonic  ("cyclothymic")  reac- 
tion type,  in  which  the  whole  personality  uniformly  participates  in  a 
definite  and  relatively  vivid  affect,  suitable  for  the  situation  of  the 
moment,  and  the  train  of  ideas  follows  substantially  quite  logical  laws, 
in  that  the  affects  disturb  it  only  by  connecting  and  overvaluing  what 
conforms  to  it,  and  by  inhibiting  and  undervaluing  what  opposes  it. 
If  at  the  same  time  the  physiologically  conditioned  mood  remains  uni- 
form throughout  life  and  maintains  an  average  pace,  the  representa- 
tives of  this  type  then  pass  as  the  most  normal  people.  If  it  perma- 
nently deviates  to  euphoric  or  depressive  paths,  its  carriers  are  then  in 
a  chronic  mood;  if  the  mood  fluctuates  (alwaj's  for  physiologic  rea- 
sons), those  so  afflicted  are  cyclothymic,  or  in  the  pronounced  cases, 
manic  depressive.  Studies  of  heredity  show  us,  that  the  peculiarities 
mentioned,  somewhere  belong  together,  that  they  represent  a  uniform 
super  quality,  the  "syntone,"  in  which,  although  the  individual  sub 
groups  follow  by  preference  a  similar  heredity,  they  can  nevertheless 
substitute  one  another  in  almost  every  family.  Manic-depressive  in- 
sanity, Cyclothymia,  chronic  depressive  and  manic  moods,  appear  as 


CLASSIFICATION  OF  MENTAL  DISEASES  175 

exaggerations  or  other  deviations  of  "normal"  syntonic  reaction 
types. 

Whereas  the  relationship  of  even  the  uniform  (most  normal)  sy.^- 
tones  to  the  morbid  fluctuations  was  first  demonstrated  by  Kretsr-hrner, 
the  "schizoid"  peculiarities  of  healthy  persons  was  long  known.  Thus 
there  is  a  lack  of  uniformity  of  the  affectivity,  actual  coexistence  of 
different,  nay,  contrasting  strivings,  and  a  slight  deviation  of  the  asso- 
ciations from  the  usual  paths.  Here  too  one  must  differentiate  the 
various  qualitative  or  quantitative  sub  groups,  which  are  frequently 
inherited  as  such,  but  still  change  frequently  within  the  main  type. 
Among  those  one  finds  persons  who  are  dereistic,  who  show  an  affective 
poverty,  who  are  irritable,  eccentric,  paranoid,  schizophrenic,  schizoid, 
etc.  Now,  even  if  the  schizoid  reaction  appears  mostly  abnormal 
following  the  canon  which  we  have  made  for  ourselves  about  psychic 
normality,  that  too  has  as  much  biologic  significance  as  the  syntones: 
Psychic  new  creations,  inventions,  political  and  religious  revolutions 
almost  always  owe  their  existence  to  it.  Exaggerations  or  caricatures 
of  this  reaction  type  come  into  existence  as  schizophrenic  manifesta- 
tions. But  whereas  according  to  our  present,  still  very  limited  knowl- 
edge, the  manic  depressive  attacks  are  designated  as  "functional," 
at  least  the  more  serious  schizophrenias  are  connected  with  tangible 
cerebral  changes;  hence  the  most  marked  deviation  from  the  normal 
seems  to  be  here  in  the  first  place  not  merely  a  strong  fluctuation  but 
something  new,  still  even  in  this  relation  it  is  nevertheless  possible 
to  form  a  parallel  syntone,  at  least  hypothetic  ally,  between  manic- 
depressive  and  schizoid-schizophrenia. 

Every  man  then  has  one  syntonic  and  one  schizoid  component,  and 
through  closer  observation  one  can  determine  its  force  and  direction 
and  can  also  put  it  in  relation  to  his  heredity,  if  the  members  of  the 
family  are  known. 

Either  both  or  only  one  of  the  reactions  may  be  morbidly  exag- 
gerated in  the  same  individual.  The  extreme  cases  then  belong  to  the 
pure  manic-depressive  and  the  pure  schizophrenic  diseases.  Fre- 
quently, however,  we  find  distinct  mixtures;  preponderating  manic- 
depressive  types  with  schizophrenic  accessory  symptoms  and  the  re- 
verse. These  mixtures  have  been  known  to  psychiatrists  for  a  long 
time,  but  they  have  been  guided  by  it  only  in  the  prognosis  and  treat- 
ment of  the  disease  but  not  in  naming  it.  Except  in  the  rare  extreme 
cases  we  now  no  longer  have  to  ask,  is  it  manic-depressive  or  schizo- 
phrenia? but  to  what  extent  manic-depressive  and  to  what  extent 
schizophrenia?  Confronted  with  such  mixed  forms  we  can  say  that 
if  the  schizophrenic  components,  though  distinct,  do  not  definitely 


176  TEXTBOOK  OF  PSYCHIATRY 

follow  the  paths  of  dementia,  the  prognosis  is  still  good,  at  least  as 
regards  the  present  attack,  otherwise  it  is  bad;  for  the  manic  depressive 
part  of  the  disease  is  almost  always  transitory. 

For  not  only  would  the  schizophrenic-like  symptoms  in  all  manic 
depressive  forms  owe  their  existence  to  schizophrenic  components,  but 
conversely  most  of  the  melancholic  and  manic  states  in  schizophrenics 
would  probably  be  an  expression  of  the  manic  depressive  components; 
they  would  really  have  no  direct  connection  with  the  schizophrenic 
process.  In  many  cases  the  latter  connection  could  always  be  made 
with  the  greatest  probability  by  studying  the  heredity. 

The  theory  has  also  some  bearing  on  other  diseases,  namely,  organic 
psychoses.  Poisons  coming  from  without  (alcohol,  infections),  as 
from  within  (uraemia),  will  set  free  more  schizoid  symptoms,  if  the 
schizoid  factors  of  the  individual  are  stronger,  and  more  manic  de- 
pressive symptoms,  the  more  syntonically  the  patient  is  predisposed. 
This  would  thus  furnish  us  with  the  explanation  not  only  for  the  mixed 
forms  of  manic-depressive  and  schizophrenic  symptoms,  but  also  for 
the  admixture  of  manic  depressive  or  schizophrenic  symptoms  in  quite 
different  diseases.  As  far  as  our  experience  goes  this  theory  can  be 
fully  applied  to  senile  dementia.  The  preponderance  of  euphoric  or 
even  manic  symptoms  in  general  paresis  requires  a  special  explanation: 
Does  the  disposition  to  manic  behavior  also  contain  a  disposition  to 
the  localization  of  the  spirochites  in  the  brain?  Or  what  seems  more 
probable,  does  the  paralytic  process  or  toxin  produce  a  tendency  to 
euphoric  reaction? 

That  under  these  circumstances  the  paraphrenias  must  all  be  added 
to  the  schizophrenias  is  self-evident.  One  thinks  less  of  the  fact  that 
also  the  essential  factor  in  all  neuroses  rests  on  schizophrenic  mecha- 
nisms ;  one  may  think  of  the  splitting  off,  the  pinching  off,  the  arraign- 
ment of  one  impulse  by  the  other,  the  inability  to  adjust  to  certain 
situations  (or  better  the  will  not  to  adjust  oneself) ,  etc.  To  be  sure 
the  syntonic  components  play  some  part  in  the  formation  of  even  these 
morbid  pictures.  Thus  to  produce  a  hysteria  in  the  ordinary  sense 
there  must  be  a  tendency  to  a  labile  affectivity  in  order  to  accentuate 
one's  own  personality;  a  more  depressive  affectivity  in  the  same 
schizophrenic  mechanism  would  lead  to  "neurasthenic"  pictures.  If 
the  affects  are  very  constant  and  maintain  themselves  in  a  more  central 
position,  a  paranoia  will  develop  in  a  schizoid  mental  type  as  a  re- 
action to  inner  and  outer  difficulties  (Studies  in  heredity  seem  at  last 
able  to  furnish  the  long  expected  proof  of  the  relationship  between 
forms  of  paranoia  and  schizophrenias) .  A  simple  uncontrollable  affec- 
tivity which  leads  to  all  sorts  of  primitive  reactions,  such  as  crying, 


f 


CLASSIFICATION  OF  MENTAL  DISEASES  177 

window  breaking,  scratching  up  the  husband,  extravagance  in  love  and 
veneration,  has  its  origin  in  the  syntonic  components. 

The  fragmentary  theory  here  presented  is  for  the  present  only  an 
hypothesis;  but  could  be  demonstrated  with  remarkable  elegance  in  a 
large  amount  of  material  of  healthy  and  sick  people;  its  correctness 
at  least  as  far  as  its  general  features  are  concerned  can  therefore 
hardly  be  doubted.  It  is  even  more  important  when  we  find  that  the 
two  psychic  types  also  show  a  certain  predilection  for  definite  physical 
constitutions;  to  be  sure  these  connections  are  more  complicated  and 
less  definite  than  those  based  on  psychic  spheres;  but  Kretschmer's 
Pyknical  physical  type,  e.g.,  must  somewhere  show  a  particular  rela- 
tion to  the  stronger  syntonic  reaction  types. ^ 

In  recent  years  anatomical  investigations  have  carried  us  forward 
very  nicely,  in  that,  for  instance,  a  clearly  circumscribed  picture  could 
be  distinguished  of  dementia  paralytica,  of  various  forms  of  senility, 
and  of  several  diseases  that  may  be  designated  clinically  as  epileptic. 

As  in  somatic  pathology  we  are  not  accustomed  in  psychiatry  to 
apply  concurrently  different  principles  of  classification,  and  through 
the  services  of  Kraepelin  we  have  attained  in  barely  two  decades  a 
point  of  view,  which  compared  with  the  earlier  one,  is  entirely  satis- 
factory. Even  though,  as  everywhere  else,  there  is  much  we  should 
know  in  order  to  see  clearly,  and  though  there  are  surely  still  many 
diseases  that  we  do  not  know,  nevertheless  compared  with  the  com- 
plete helplessness  of  previous  years  we  have  achieved  a  point  of  view 
from  which  it  is  possible  to  gain  new  ground  steadily. 

Therefore  I  follow,  as  far  as  possible,  Kraepelin's  classifioation, 
which  is  now  pretty  well  understood  in  the  whole  world,  even  if  it  is 
not  everywhere  accepted,  while  all  other  schematizations  are  viable 
only  in  certain  schools. 

Combinations  of  psychoses  are  still  insufiicintly  studied.  A  schizo- 
phrenic or  a  manic  depressive  patient  may  be  taken  with  fever- 
delirium,  delirium  tremens,  paresis,  or  dementia  senilis;  alcoholism 
is  not  at  all  rare,  especially  in  women  where  it  is  a  symptom  of 
schizophrenia.  In  such  cases  the  symptoms  of  the  two  psychoses 
combine  and  under  certain  circumstances  as  in  the  interconnected 
hallucinations  of  the  schizophrenic  delirium  tremens,  thej'  fuse  into  a 
unified  and  peculiar  nuance.  Sometimes  one  disease  apparently  forms 
the  essential  picture ;  there  is  no  pronounced  second  disease  but  a  mere 
predisposition  colors  the  symptoms. 

^  For  more  information  see  Kretschmer  Korperbau  und  Charakter.  Springer, 
Berlin  1921,  and  Bleuler:  Die  Probleme  der  Schizoidie  und  der  Syntonie,  Zeitechr. 
f.  d.  gesam.  Neurol,  u.  Psychiat.  1922. 


178  TEXTBOOK  OF  PSYCHIATRY 

Recently  an  attempt  was  made  to  place  the  classification  of  the 
psychoses  on  an  entirely  different  basis  by  emphasizing  the  various 
factors  participating  in  the  causation,  development,  and  course.  I 
made  the  effort  to  initiate  these  viewpoints  also  here  but  had  to  desist 
from  it.* 

Even  if  only  the  most  important  combinations  would  have  been 
presented  it  would  have  been  so  complicated  that  not  alone  the  be- 
ginner would  have  had  much  trouble  in  understanding  them.  On  the 
other  hand  if  one  is  well  acquainted  with  the  present  grouping  of  the 
symptoms,  it  is  no  longer  a  clever  feat  to  recognize  and  sufficiently 
differentiate  in  the  same  patients  such  conditions  as  congenital  de- 
bility, alcoholism,  manic  states,  and  perhaps  even  the  beginning  of 
senile  dementia.  If  the  new  demands  would  be  followed  many  repeti- 
tions would  be  unavoidable.  Moreover  our  knowledge  is  by  far  too 
meagre  for  such  description.  Thus  in  the  case  of  apparently  catatonic 
symptoms  in  organic  psychoses,  we  must,  for  example,  first  find  out 
whether  and  to  what  extent  they  are  based  on  the  same  schizoid 
mechanisms  as  in  schizophrenia  before  we  can  say  in  a  given  case 
that  the  morbid  picture  is  colored  by  a  schizoid  disposition.  We  do 
not  know  the  somatic  (toxic?)  part,  that  probably  conditions  the 
tendency  to  euphoria  and  mania  in  paresis,  and  consequently  cannot 
tell  to  what  extent  an  induced  paretic  mania  results  from  the  disposi- 
tion, etc. 

Besides,  the  diagnosis  in  the  present  sense  still  remains  the  im- 
portant factor.  If  we  formulate  our  findings  in  such  words  as  "or- 
ganic disease,"  "''epilepsy,"  "manic  depressive  insanity,"  or  "neurosis," 
we  have  at  the  same  time  drawn  from  it  the  most  important  practical 
and  theoretical  consequences,  which  at  least  for  the  present  cannot  be 
substituted  by  any  other  theory.  What  would  be  the  use  of  recogniz- 
ing an  hysterical  mechanism,  if  we  would  not  know  whether  it  de- 
veloped on  a  schizophrenic,  paretic,  epileptic,  or  on  a  mere  nervous 
constitution?  And  if  instead  of  calling  a  disease  schizophrenia  we 
would  have  to  describe  all  the  individual  mechanisms  which  we  see 
acting  in  unison,  we  would  hardly  ever  get  through,  and  we  would 
then  still  have  to  keep  the  whole  story  in  our  heads,  in  order  to  decide 
upon  the  prognosis  and  treatment.  Also  the  two  latter  deductions 
could  be  the  same  as  in  any  other  psychosis,  which  is  composed  of 
quite  different  individual  syndromes,  that  is,  it  would  look  quite 
different  in  the  description,  but  would  become  attached  to  the  former, 
without  anything  further,  through  the  diagnosis  of  schizophrenia. 

The  first  thing  to  consider  in  the  "Strata-diagnosis"  ("Schichtdiag- 

*  Comp.  also  the  end  of  Chapter  IX  on  "syndromes,"  p.  198. 


CLASSIFICATION  OF  MENTAL  DISEASES  179 

nose")  of  Kretschmer  is  the  constitution,  whereby  there  is  tendency  of 
late  to  understand  only  something  acquired  through  heredity,  although 
it  is  natural  to  suppose  that  some  qualities,  as  e.g.,  the  weakness  of 
an  endocrine  gland,  can  be  just  as  well  acquired  as  congenital.  But 
the  constitution  even  in  this  narrow  sense  is  by  no  means  a  factor 
acting  only  in  one  way.  It  acts  pathogenetically  when  it  gives  direct 
origin  to  an  amaurotic  idiocy,  to  a  schizophrenia,  or  a  manic  depressive 
insanity;  it  acts  "pathoplastically"  (Birnbaum)  when  as  a  schizoid 
disposition  it  determines  the  formation  and  the  kind  of  delusions  in  an 
organic  disease,  or  when  it  causes  an  alternation  of  manic  and  depres- 
sive moods  in  the  same  disease.  In  the  latter  case  it  influences  besides 
the  course  of  the  external  morbid  picture,  and  it  is  assumed  that  it 
can  determine  the  severity  of  the  disease  in  its  manifestation  and 
outcome. 

The  concept  of  disposition  includes  the  constitution  and  with  it 
also  all  the  not  familiar  factors,  congenital  and  acquired,  that  may 
come  into  consideration,  such  as  poisons,  infections,  traumas  and 
physical  diseases  of  various  kinds.  It  acts  exactly  like  the  constitu- 
tion: pathologically,  pathoplastically,  and  determines  the  course  and 
the  severity  of  the  disease. 

A  particularly  conspicuous  side  of  the  disposition  is  the  character, 
which  acts  pathoplastically;  thus  certain  ideas  of  persecution  and 
grandeur  are  only  possible  in  definite  strivings  and  in  definite  char- 
acterological  relations  to  the  environments;  the  economical  person  be- 
comes miserly  in  senile  dementia. 

But  indirectly  the  character  also  acts  pathogenetically,  not  only  by 
assisting  in  the  acquisition  of  a  syphilis  or  an  alcoholism,  but  also 
probably  through  the  fact  that  certain  diseases,  like  paranoia  or  even 
paranoid  conditions,  i.e.,  diseases  w^hich  are  made  up,  as  it  were,  of 
delusions,  would  not  have  broken  out,  if  the  character  would  not  have 
assisted  in  determining  the  possibility  of  delusional  formation.  The 
neuroses  too  require  a  soil  of  a  definite  character  foundation. 

However,  the  character  may  also  be  the  result  of  a  morbid  dis- 
position, which  later  leads  to  a  psychosis  (schizophrenia,  manic  de- 
pressive insanity,  epilepsy),  or  it  may  be  the  partial  manifestation  of 
the  disease  (oligophrenia,  schizophrenia  epilepsy),  or  it  is  the  disease 
that  first  emphasizes  definite  features  of  character,  exaggerates,  or 
caricatures  them  (a  punctual  and  conscientious  person  becomes  quer- 
ulous in  old  age,  the  generous  becomes  thoughtless,  and  the  one  who 
is  somewhat  below  par  morally  becomes  an  unscrupulous  criminal  as 
a  schizophrenic). 

Quite  independent  of  the  disposition,  as  far  as  its  psychic  expres- 


180  TEXTBOOK  OF  PSYCHIATRY 

sion  is  concerned,  is  the  part  played  by  individual  cerebral  processes 
which  change  the  material  foundations  of  the  psychic  life.  Among 
the  first  to  be  named  is  the  diffuse  atrophy  of  the  brain,  that  is,  its 
cortex,  which  in  very  different  diseases  is  the  most  essential  factor  for 
the  structure  of  the  psychic  picture  of  the  symptoms ;  and  quite  inde- 
pendent of  all  other  manifestations  and  dispositions  determines  what 
we  call  clinically  "organic  mental  diseases."  In  reference  to  the 
psychosis  the  cerebral  alteration  acts  pathogenetically,  while  in  refer- 
ence to  the  symptomatology  pathoplastically.  That  the  localization, 
and  the  kind  of  the  process  leading  to  the  atrophy  must  exert  a  forma- 
tive influence  on  the  distributions  of  the  picture,  which  we  consider 
as  accessory  manifestations,  is  self-evident.  But  as  yet  we  know  too 
little  about  it  to  give  these  factors  serious  consideration.  The  invasion 
of  the  spirochites  exerts  a  tendency  to  euphoria;  certain  senile  proc- 
esses like  cerebral  pressure  determine  a  torpor  of  all  psychic  processes. 
Multiple  sclerosis  (and  epilepsy)  and  other  organic  brain  diseases 
dispose  one  to  hysteroid  symptoms,  while  paresis  and  senile  dementia 
often  cause  them  to  recede. 

Circumscribed  injuries  of  the  brain  also  come  into  consideration 
both  in  regards  to  causation  as  well  as  formation.  Lesions  in  the 
basal  ganglia  diminish  the  energy  from  the  impulsive  life  (sleeping 
sickness) ;  other  lesions  at  the  base  of  the  frontal  lobe  lead  to  moria, 
facetiousness,  and  a  tendency  to  mischievous  teasing.  Other  circum- 
scribed lesions  in  the  basal  ganglia  determine  a  labile  affectivity,  while 
all  destructions  of  parts  of  the  brain  are  likely  to  produce  irritability 
and  transient  moodiness. 

Congenital  dispositions  also  influence  the  form  of  the  symptoms 
in  these  cases,  in  that  the  force  of  the  schizoid  functions  adds  to  the 
picture  schizophrenic  symptoms,  and  pronounced  syntony  manic  de- 
pressive symptoms;  the  other  dispositions  of  character  also  color  the 
disease.  That  former  experiences,  e.g.,  delusions,  can  color  the  organic, 
and  that  poisons  (alcohol)  can  influence  the  entire  psychic  picture  even 
here,  is  well  known. 

More  difficult  is  the  formation  of  the  theory  in  epilepsy.  The 
epileptic  process  (chemical  or  anatomical)  produces  a  marked  change 
in  the  psyche,  but  only  in  the  same  direction  as  the  epileptoid  founda- 
tion showed  itself  before  the  appearance  of  the  disease  in  the  patient 
himself  or  at  the  same  time  in  his  blood  relationship.  We  shall  there- 
fore do  well  here  to  reserve  our  theory  for  a  while. 

Still  more  complicated  are  the  relations  in  schizophrenia.  Here 
too  there  is  a  disposition,  which  psychically  shows  itself  as  an  embryo 
of  the  later  insanity,  then  there  are  elementary  disturbances  in  the 


CLASSIFICATION  OF  MENTAL  DISEASES  181 

thought  apparatus,  wliich  are  still  hard  to  understand,  somewhat  lat^.-r 
or  in  acute  shifts  there  are  distinct  organic  changes  in  the  brain  and 
on  the  top  of  this  as  accessories  there  develops  the  entire  polymorphous 
complex  of  the  schizophrenic  manifestations,  as  reactions  of  a  sick 
organism,  or  as  deviated  functions  of  the  psyche. 

Besides  the  epileptoid  and  schizoid  characteristics,  which  have 
some  connection  with  the  disease  itself,  other  qualities  of  character 
must  naturally  co-determine  in  many  directions  the  outward  appear- 
ance of  the  psychosis. 

Some  toxins,  like  alcohol,  morphine,  and  cocaine,  act  causatively 
and  at  the  same  time  formatively,  so  that  one  can  tell  the  cause  from 
the  picture;  in  their  manifestations  these  poisons  are  also  definite 
forms  of  psychic  disturbances. 

When  different  causes  producing  definite  symptom  complexes  co- 
operate, for  instance,  a  spirochite  invasion  and  an  alcohol  poisoning, 
it  is  customary  to  view  the  one  disease  as  the  essential  and  the  ad- 
mixtures of  the  other  as  a  "coloring"  of  the  same.  In  a  delirium 
tremens  we  sometimes  find  the  signs  of  paresis,  in  senile  dementia 
those  of  alcoholism.  As  a  matter  of  fact,  it  concerns  here  a  mixture 
of  two  diseases,  of  which,  to  be  sure,  the  one  without  the  other  would 
often  not  come  to  light.  Similar  conditions  prevail  when  only  dis- 
positions, and  not  a  pronounced  disease  complicate  the  main  psychosis. 
Febrile  deliria,  and  delirium  tremens,  are  influenced  by  schizoid 
factors,  schizophrenia  by  alcoholism,  in  that,  e.g.,  the  hallucinations 
and  delusions  become  more  united.  A  schizoid  disposition  or  schizo- 
phrenia and  the  effect  of  alcohol  mix  with  a  uniform  picture,  in  acute 
alcoholic  delusions,  in  so  far  as  the  tw'o  components  are  even  much 
less  separable  than  the  alga?  and  fungi  among  the  lichens. 

The  psychosis  or  the  disposition  can  also  counterbalance  the  other 
in  individual  symptoms:  organic  psychoses  loosen  the  blockings  and 
other  catatonic  manifestations  of  schizophrenia.  The  original  char- 
acter can  be  turned  into  its  opposite. 

There  are  also  definite  syndromes  ("diseases")  which  are  produced 
by  definite  causes  or  cerebral  processes.  On  the  other  side  it  has 
been  said  that  similar  causes  may  produce  different  pictures  of  dis- 
ease, depending  on  the  reaction  type  of  the  patient.  Thus  a  fever,  an 
alcoholic  poisoning,  a  delirium  tremens,  a  paresis,  even  a  manic  de- 
pressive attack  will  set  free  schizophrenic  symptoms  in  a  schizoid 
individual.  Depending  on  the  disposition,  psychic  influences  will 
evoke  twilight  states,  hysterical  attacks,  a  neurasthenia,  a  schizo- 
phrenic attack,  or  chronic  delusional  formations.  The  correct  concept 
is  that  a  disposition  and  a  chance  cause  manifest  themselves  in  the 


182  TEXTBOOK  OF  PSYCHIATRY 

morbid  picture  in  just  such  cases,  or,  what  is  the  same,  that  two 
causes  participate  in  the  formation  of  the  picture. 

Individual  diseases  are  direct  products  of  the  disposition:  they  are 
nothing  but  the  expressions  of  the  congenital  disposition,  which  mani- 
fests itself  at  a  certain  age  (amaurotic  idiocy,  process  shifts  of  schizo- 
phrenia, arteriosclerosis).  We  assume  that  in  accordance  with  fate 
the  disease  would  here  break  out  under  all  circumstances.  Neverthe- 
less in  the  individual  case  some  still  think  of  chance  causes,  which 
were  necessary  to  set  free  the  disease,  or  have  at  least  participated 
in  some  way  (reenforcing,  hastening  the  outbreak)  in  the  success  of 
the  disease.  Precisely  in  arteriosclerosis  one  always  looks  for  external 
causes. 

Besides,  the  layman,  and  even  now  many  physicians  still  have  the 
same  idea  about  the  appearance  of  a  disease,  to  which  one  is  predis- 
posed, as  about  the  appearance  of  a  running  nose  through  a  cold.  In 
addition,  when  it  is  a  question  of  the  psychoses  one  thinks  mostly  of 
psychic  injuries.  But  as  far  as  temporary  injuries  are  concerned, 
there  is  not  the  least  basis  in  experience  for  such  an  assumption. 
People  who  consider  it  quite  obvious  that  any  unfortunate  occurrence 
"can  drive  one  crazy,"  and  that  confinement  in  the  insane  asylum 
will  "surely  make  one  crazy,"  mistake  transient  reactions  for  perma- 
nent maladies  resulting  from  dispositions.  Only  where  the  harmful 
influence  is  permanent  can  it  sustain  a  permanent  reactive  psychosis: 
delusion  of  being  pardoned  in  life-prisoners,  paranoid,  or  damage  suit 
neurosis.  And  when  we  speak  in  such  cases  of  a  "disposition"  for 
the  concerned  diseases,  the  expression  means  here  something  quite 
different  than  the  disposition  for  schizophrenia  or  for  arteriosclerosis, 
which  in  the  light  of  hitherto  conceptions  is  nothing  but  the  germ 
of  the  disease,  whereas  in  the  latter  examples  the  disease  represents 
only  an  accidental  special  reaction  to  a  general  reactive  predisposition. 

As  to  the  very  different  things  that  are  understood  by  "occasion  for 
something"  ("Anlass"),  and  what  causative  and  at  the  same  time 
formative  meanings  it  conveys,  is  too  familiar  to  require  here  more 
than  a  few  suggestions.  In  the  vocation  of  the  saloonkeeper  there  is 
the  "occasion"  for  becoming  an  alcoholic,  in  the  war,  for  dreaming 
or  hysterical  manifestation,  in  fever  or  in  a  nephritis,  there  is  the 
occasion  for  a  catatonically  colored  delirium,  in  alcoholism  for  the 
outbreak  of  epilepsy,  in  Bright's  disease  for  an  amentia,  in  a  fracture 
of  the  head  of  the  femur  or  in  an  exhaustive  disease  for  a  senile 
dementia,  and  in  childbirth  for  a  schizophrenic  shift.  The  latter  con- 
nection as  well  as  the  hysterical  manifestations  with  their  causes  belong 
in  the  sphere  of  the  psychogenetic,  which  are  not  unknown  in  the 


CLASSIFICATION  OF  MENTAL  DISEASES  183 

present  time;  an  exaggerated  or  qualitatively  abnormal  stimulus  in 
a  corresponding  disposition  leads  to  a  psychosis  or  neurosis;  the  same 
happens  in  the  case  of  a  normal  stimulus,  if  the  kind  or  force  of  the 
reactivity  is  abnormal. 

Still  more  could  be  said  about  the  "structure  of  the  psychosis"; 
the  material  mentioned  should  show  only  about  what  points  of  view 
come  into  consideration,  and  how  complicated  are  the  various  factors 
influencing  one  another.  Analogous  points  of  view  could  also  be 
considered  in  the  study  of  the  demolition,  improvement,  and  flattening 
down  of  the  diseases. 


CHAPTER  Vm 

THE  RECOGNITION  OF  INSANITY 

In  the  diagnosis  of  insanity  in  general  it  is  hardly  ever  possible 
to  obtain  in  a  single  examination  a  complete  morbid  picture,  or  to 
follow  a  general  plan  of  examination.^  One  would  never  finish  and 
would  worry  or  irritate  the  patient  unnecessarily.  And  only  at  excep- 
tional times  is  it  feasible  to  keep  to  a  definite  procedure  in  the 
examination.  When  the  patient  indicates  a  symptom  to  us,  e.g.,  an 
hallucination,  it  is  usually  advisable  to  follow  the  trail  at  once.  Often, 
too,  w^e  are  forced  to  verify  only  a  few  cardinal  symptoms  and  of 
the  others  as  much  as  is  still  necessary  and  possible  under  the 
circumstances. 

But  in  this  respect  one  must  not  be  too  modest;  the  more  one 
knows,  the  more  certain  the  diagnosis  and  the  mnrp  dpfiTiite-iim-±hpTp- 
peijtic-Baeg^uresy^  Theliumah  psyche  is  so  complex  that  much  that  at\ 
irst  seems  a  sure  symptom  of  a  definite  mental  disease  is  not  infre- 
quently explained  as  something  else  when  all  the  circumstances  are 
known.   )^  frequeTitly--suffices^  to   make_oiily-H±'e   dlHgnosia   of-4b€ — . 

disease  without,  however,  ascertaining  the  particular  psychosis. 
This  is  the  case  when  an  excited,  or  violent,  or  fasting,  or  suicidal 
patient  is  to  be  committed  to  a  hospital  as  quickly  as  possible.  The 
eventual  necessity  of  a  neurological,  ophthalmoscopic,  and  general 
physical  examination  should  always  be  borne  in  mind. 

Since  a  general  examination  is  not  possible  as  in  somatic  diseases 
where  one  begins  at  the  head,  and  ends  with  the  feet,  the  only  thing 
to  do  is  to  follow  up  those  symptoms  which  one  was  called  to  treat 

*  Plans  for  examination  have  been  devised  which  naturally  take  into  con- 
sideration ever>'thing  existing  and,  for  that  reason,  must  give  a  too  large  number 
of  view-points.  It  may  be  a  good  thing  for  a  beginner  to  read  them  through 
carefully  and  note  ever>'thing  that  might  be  considered.  But  in  the  examination 
itself  one  must  be  able  to  hit  upon  the  selection  necessary  for  the  special  case, 
not  only  in  the  interest  of  the  patient,  but  especially  of  the  physician  who 
otherwise,  as  experience  shows,  easily  neglects  the  important  point.  This  im- 
portant point,  namely,  the  examination  of  the  chief  symptoms  with  their  theo- 
retical and  practical  associations,  simply  does  not  permit  of  schematization  and, 
therefore,  compared  with  the  remaining  trifles  in  the  scheme,  necessarily  falls 
short. 

184 


THE  RECOGNITION  OF  INSANITY  185 

or  that  immedifitely  strike  one's  eye,  and  think  of  those  diseases  that 
can  produce  such  manifestations,  and  then  look  around  for  other  signs 
of  the  disease.  If  the  suspicion  is  neither  positively  nor  partially  con- 
firmed, then  other  possibilities  will  have  to  be  considered.  In  order 
to  do  this,  it  is  necessary  to  carry  in  one's  head  the  symptomatology 
of  at  least  the  more  important  individual  diseases. 

The  kind  of  questioning  is  of  the  greatest  importance.  In  the  finst 
place,  if  it  is  at  all  possible,  one  must  not  irritate  the  patient  until 
the  most  important  information  has  been  obtained.  It  is  much  better 
to  gain  his  confidence,  naturally  without  taking  him  in.  An  examina- 
tion under  false  pretenses  should  be  avoided.  If  a  patient  does  not 
talk,  a  physical  examination  can  be  made,  perhaps  occasionally,  as  if 
by  accident,  a  question  may  be  put  to  him  as  "Does  this  hurt?"  or 
something  similar  and  so  induce  the  patient  to  speak.  One  can 
observe  much  in  both  the  mental  and  physical  field  without  the 
patient's  noticing  it;  thus  one  can  become  accustomed  to  notice  the 
pupilary  reactions  in  an  ordinary  conversation.  One  will  always  keep 
in  mind  the  whole  situation  as  it  appears  to  the  patient.  The  identical 
question  with  or  without  introduction  may,  in  one  situation  or  another, 
be  a  very  good  one,  or  such  that  it  makes  the  patient  unfit  for  a  further 
examination.  "How  much  is  twice  two?"  may  be  a  good  question  but 
under  other  circumstances  it  may  suggest  to  the  patient  another  ques- 
tion, viz.,  whether  the  physician  is  crazy.  A  test  of  the  sense  of  pain 
with  needle  pricks  is  something  entirely  different  if  the  patient  is 
distracted  or  not,  if  one  dashes  at  him  with  the  instrument,  or  first 
begs  him  to  indicate  whether  he  notices  the  prick,  etc.  In  short,  in 
these  matters  one  must  have  some  practice  and  above  all  native  tact 
and  comprehension  of  the  situation  and  the  consequences,  otherwise 
all  special  directions  and  details  are  useless. 

One  must  never  forget  that  the  examination  in  the  clinic, 
where  the  examiner  usually  knows  the  patient  and  where  the  entire 
situation  facilitates  many  questions,  is  entirely  different  from  the 
examination  in  a  first  consultation.  The  latter  requires  much  greater 
care. 

Naturally,  whenever  possible,  one  endeavors  to  obtain  a  good 
anamnesis.  If  this  is  possible  before  the  examination,  it  can  materially 
shorten  the  entire  procedure,  since  in  many  cases  one  then  needs  only 
a  confirmation  of  its  important  data  by  the  patient  to  be  sure  of  the 
diagnosis.  But  even  after  the  examination  one  must  not  hesitate  to 
supplement  or  obtain  the  anamnesis,  because  only  now  does  one  know 
in  all  respects  the  drift  of  the  situation.  In  this  matter  one  must 
not  be  too  gullible.    No  anamnesis  is  entirely  impartial;  purposely  or 


186  TEXTBOOK  OF  PSYCHIATRY 

accidentally  with  good  or  bad  intentions,  a  great  deal  is  invented  both 
on  the  good  and  the  bad  side.  One  should  be  especially  careful  about 
an  anamnesis  which  is  obtained  from  the  patient  himself.  Correctly 
used,  it  frequently  furnishes  an  absolutely  clear  diagnosis  despite  the 
patient's  wishes. 

Something  entirely  different  from  a  single  examination  is  a  com- 
plete examination  or  observation  which  is  usually  necessary  in  giving 
a  professional  opinion.  Here  one  must  be  assisted  by  the  other  de- 
partments which  the  clinic  offers  and  possibly  by  other  specialists, 
such  as  the  examinations  of  the  eyes,  ears,  blood,  fluids,  etc.  This 
technique  must  be  acquired  in  institutions  or  at  least  from  textbooks. 
Such  examinations  can  usually  only  be  done  in  institutions. 

The  intelligence  examination  will  be  discussed  in  the  chapter  on 
Oligophrenia. 

If  a  case  is  not  clear  without  it  and  under  all  circumstances,  if 
one  must  handle  the  patient  oneself,  a  minute  physical  and  especially 
neurological  examination  must  not  be  omitted. 

In  patients  who  are  inclined  to  assume  tense  attitudes  or  who  are 
otherwise  awkward,  the  patella  reflexes  are  best  taken  not  with  the 
knees  crossed  but  with  the  feet  somewhat  forward  and  the  whole  sole 
resting  flat  on  the  ground.  If  they  are  absent,  they  can  sometimes 
be  obtained  by  Buzzard's  method,  that  is,  by  raising  the  heels  in  this 
position  with  the  point  of  the  foot  left  on  the  ground. 

In  testing  the  pupillary  reflexes  the  beginner  often  makes  mistakes. 
The  directions  recommended  for  avoiding  them  are  contradictory; 
clinical  experience,  one's  own  good  sense,  care  and  adaptation  to  the 
special  case  must  help  along. 

One  does  well  to  observe  the  pupillary  reflexes  while  conversing 
with  the  patient.  In  doubtful  cases  the  room  should  be  darkened 
and  lighted.  Restricted  sources  of  light,  especially  the  pocket  flash 
light,  are  likely  to  result  in  false  reactions.  Touching  the  lids  is  often 
responded  to  by  patients  with  irritability  or  stubbornness.  One  should 
be  careful  not  to  confuse  in  the  insane,  light — and  accommodation — 
and  psychic  reactions. 

For  examination  of  cerebrospinal  fluid  see  the  section  on  organic 
psychoses  in  general  (p.  238). 

Clinical  experience  alone  can  teach  the  technique  of  mental  exami- 
nations. One  must  know  from  observation  what  a  blocking  or  a  rigid 
mimicry  is;  whoever  would  depend  on  theoretical  descriptions  will  be 
helpless  before  the  patient,  or  make  the  crassest  mistakes.  Most 
psychic  symptoms  are  exaggerations  of  normal  mechanisms;  for  that 
reason  one  must  not  only  see  them,  but  also  evaliiate  them.    Whether 


THE  RECOGNITION  OF  INSANITY  187 

an  affective  stupor,  a  blocking,  or  a  speech  disturbance  is  pathological 
cannot  be  described,  and  still  less  whether  these  matters  are  patho- 
gnomonic of  a  particular  disease.  Clinical  experience,  too,  must  teach 
one  to  understand  the  descriptions  with  the  necessary  grain  of  salt. 
Words  cannot  do  more  than  seize  upon  a  pronounced  "typical"  facies 
from  the  endless  variety  of  psychic  manifestations;  only  observation 
can  decide  to  what  extent  such  an  example  should  be  generalized  and  to 
what  extent  not. 

As  far  as  the  individual  functions  are  concerned,  attention  should 
be  called  to  the  following 

Whether  the  patient  is  oriented,  usually  shows  of  itself.  When 
necessary,  a  few  questions  will  make  for  certainty. 

Even  the  layman  can  recognize  sense  deceptions  usually  from  some 
contradiction  with  ordinary  experience,  although  in  individual  cases 
one  will  have  to  prove  the  reality  of  the  perceptions.  A  great  many 
hallucinations  may  be  recognized  by  the  fact  that  they  cannot  be 
described  in  such  detail  as  a  perception.  Like  dreamers,  the  patients 
often  hallucinate  only  what  matters  to  them;  they  can  see  a  part  of 
a  body,  but  then  rather  imagine  the  person  to  whom  it  belongs  than 
perceive  him.  Concerning  the  voices,  the  patient  at  times  gives  only 
the  sense;  the  hallucinator  cannot  say  which  of  several  synonymous 
expressions  he  has  heard,  or  even  when  he  states  it  positively,  he  fre- 
quently contradicts  himself  in  repeated  accounts.  Upon  exact  ques- 
t'oning  the  illusions  often  are  differentiated  from  reality  as  "pictures," 
or  "inner  voices,"  or  something  similar.  But  there  are  many  excep- 
tions; the  visual  hallucinations  of  delirium  tremens  are  especially 
distinguished  for  their  detailed  elaboration. 

Direct  questions  concerning  hallucinations  are  frequently  incor- 
rectly answered  in  the  negative  (denial,  inhibition) ;  with  patients 
whom  one  does  not  yet  know,  it  is  advisable  to  inform  oneself  indi- 
rectly through  such  questions  as  "Do  you  sleep  well?  Does  any  one 
disturb  you?  Do  the  neighbors  concern  themselves  with  j'ou  much?" 
etc. 

Similarly  in  delusions.  Where  their  content  does  not  prove  incor- 
rect from  the  first,  one  should,  when  possible,  test  their  objectivity. 
But  this  is  not  the  only  criterion  and,  precisely  considered,  not  at  all 
the  decisive  one.  A  mistake  involves  also  an  incorrect  judgment,  and 
a  delusion  may  by  chance  correspond  with  reality.  It  would  be  really 
futile  to  examine  the  objective  foundation  of  a  jealousy  delusion;  the 
decisive  factor  is  the  patient's  subjective  confirmation  of  it.  If  for 
his  firm  conviction  he  offers  no  other  grounds  than  that  his  wife's 
bed  was  once  particularly  warm,  that  twice  in  succession  the  same 


188  TEXTBOOK  OF  PSYCHIATRY 

man  met  her  as  she  was  leaving  the  house,  that  she  looked  frightened 
when  the  patient  came  home  unexpectedly,  then  it  is  a  question  of 
delusions  whether  the  wife  is  in  reality  faithful  or  not. 

In  many  cases,  perception  is  naturally  tested  indirectly.  One  can 
easily  see  whether  people  see  and  hear  correctly.  One  will  notice 
how  quickly  they  comprehend  questions,  whether  one  must  repeatedly 
explain  things,  and  for  what  reasons.  Optical  comprehension  can 
also  be  tested  by  reading;  especially  convenient  for  this  examination 
are  suitable  pictures  that  are  not  too  large,  which  one  quickly  uncovers, 
and  then  covers,  but  in  this  connection  one  must  know  what  may  be 
expected  from  a  normal  person. 

In  most  cases  the  associations  need  not  be  specially  examined; 
every  conversation,  especially  when  one  lets  the  patient  talk,  is  an 
association  test.  Milder  flight  of  ideas  becomes  evident,  if  one  stimu- 
lates the  patients  somewhat  and  lets  them  tell  what  interests  them. 
The  association  experiments  which  are  ordinarily  unnecessary  have 
to  be  practised  somewhat  if  one  wants  to  use  them. 

Memory  is  already  tested  in  taking  an  autanamnesis ;  many  ques- 
tions can  be  put  in  such  a  way  that  they  will  throw  light  also  on  this 
function.  The  memory  for  happenings  in  the  course  of  the  examina- 
tion (impressibility)  is  examined  by  again  asking  the  patient  after  a 
little  while  what  was  discussed  in  the  beginning  and  by  having  him 
repeat  examples  that  have  been  given  him.  Isolated  numbers  of  from 
four  to  six  digits  and  rare  words  or  whole  sentences  very  often  cannot 
be  reproduced  at  once  even  by  healthy  persons  when  they  are  some- 
what excited.  At  all  events,  one  must  make  sure  that  the  patients 
understood  what  was  said  to  them  and  to  a  certain  degree  compre- 
hended it. 

Affectivity  can  be  examined  directly  only  in  very  few  cases; 
one  can  always  see  how  the  patient  reacts;  furthermore  one  can 
give  him  an  opportunity  to  show  a  difference  in  his  reac- 
tion to  important  matters  and  to  trifles,  and  to  exhibit  morbid 
lability,  etc. 

For  anomalies  of  the  impulses  one  must  usually  question,  if  they 
are  not  indicated  in  the  anamnesis;  but  perversions  like  homosexuality 
and  similar  anomalies  are  often  indicated  in  the  whole  behavior  and 
in  the  dress  of  the  patient. 

If  in  order  to  test  different  functions  one  wants  the  patients  to  read 
and  recount  a  story,  the  following  illustrations,  according  to  our  experi- 
ence, are  especially  well  adapted  for  it,  obviously  because  they  contain 
repetitions.  The  first,  exacts  the  easiest  and  the  last,  the  most  difficult 
demands: 


THE  RECOGNITION  OF  INSANITY  189 

The  Donkey  Loaded  with  Salt 

A  donkey,  loaded  with  salt,  had  to  wade  a  stream.  He  fell  down 
and  for  a  few  moments  lay  comfortably  in  the  cool  water.  When  he 
got  up  he  felt  relieved  of  a  great  part  of  his  burden  because  the  salt 
had  melted  in  the  water.  Longears  noted  this  advantage  and  at  once 
applied  it  the  following  day  when,  loaded  with  .sponges,  he  again 
went  through  the  same  stream. 

This  time  he  fell  purposely  but  was  grossly  deceived.  The  sponges 
had  soaked  up  the  water  and  were  considerably  heavier  than  before. 
The  burden  was  so  great  that  he  succumbed. 

A  remedy  does  not  do  for  all  cases. 

Neptune  and  the  Laborer 

A  day  laborer  worked  along  a  stream.  By  accident  his  ax  fell  in 
and,  as  the  stream  was  so  deep  that  he  could  not  get  it  out,  he  sat  on 
the  bank  and  bemoaned  his  fate  to  the  river  god. 

Neptune  took  pity  on  the  man's  poverty,  dived  down  and  brought 
up  a  golden  ax.  "Is  this  yours?"  he  asked  the  laborer.  The  latter 
honestly  answered  "no."  Suddenly  Neptune  dived  down  again  and 
appeared  before  the  woodcutter  with  a  silver  ax.  To  this  one,  too,  the 
laborer  made  no  claim.  For  the  third  time  the  god  dived  and  brought 
up  the  right  iron  ax  with  the  wooden  handle.  "Yes,  that  is  it.  That 
is  the  right  one.  That  is  the  one  I  lost,"  the  laborer  exclaimed  joy- 
fully. "I  only  wanted  to  test  you,"  replied  Neptune;  "I  am  glad  that 
you  are  as  honest  as  you  are  poor.  There,  take  all  three  axes;  I 
present  them  to  you." 

The  honest  man  told  this  story  to  several  acquaintances.  One  of 
these  wanted  to  misuse  Neptune's  goodness  and  for  this  reason  he 
purposely  threw  his  ax  into  the  stream.  Hardly  had  he  begun  to 
bemoan  his  fate  to  the  river  god  when  the  latter  appeared  with  a 
golden  ax.  He  asked,  "Is  this  the  one  that  fell  into  the  stream?"  He 
quickly  exclaimed,  "Yes,  that  is  it,"  and  grabbed  for  it.  But  Neptune 
denounced  him  as  a  shameless  liar  because  he  wanted  to  deceive  even 
a  god  and  turned  his  back  on  him.  With  him  disappeared  the  golden 
ax  and  the  laborer  had  to  go  home  without  even  his  own  ax. 

Honesty  is  the  best  policy. 

A  Miser  Trick 

The  inhabitants  of  Cufa  were  considered  the  stingiest  Arabs.  Once 
one  of  them  heard  that  in  Bassora  there  lived  a  miser  from  whom  all 
stingy  ones  might  learn  something.     When  he  came  to  him  he  frankly 


190  TEXTBOOK  OF  PSYCHIATRY 

confessed  the  reason  for  his  visit.  "You  are  welcome,"  said  he  from 
Bassora;  "we  will  go  to  the  market  and  shop." 

They  went  to  the  baker.  "Have  you  good  bread?"  "At  your 
service,  gentlemen,  fresh  and  white  as  butter!" — "You  see,"  said  the 
man  from  Bassora  to  him  from  Cufa,  "Butter  must  be  better  than  bread 
because  bread  is  compared  with  butter.  We  will,  therefore,  do  better 
to  buy  butter." 

They  went  to  the  butter  dealer  and  asked  if  he  had  good  butter. 
"At  your  service,  butter  as  fresh  and  sweet  as  olive  oil!"— "You  hear," 
said  the  host,  "The  best  butter  is  compared  with  oil,  this  will  therefore 
be  better." 

They  went  to  the  oil  merchant.  "Have  you  good  oil?"  "Of  the 
best,  light  and  clear  as  water!"  "Hoho,"  said  the  man  from  Bassora 
to  him  from  Cufa,  "according  to  that  water  is  the  best  of  all!  I  still 
have  a  whole  barrel  at  home  with  which  I  will  serve  you  liberally." 

In  fact  he  served  his  guest  nothing  but  water  since  water  was 
better  than  oil,  oil  better  than  butter  and  butter  better  than  bread. 
"Good,"  said  the  miser  from  Cufa,  "I  did  not  come  here  in  vain;  I 
have  learned  much." 

Under  certain  circumstances  one  can  draw  conclusions  concerning 
attention,  impressibility,  registering  in  general,  if  after  the  patients 
have  been  some  time  in  a  room  unknown  to  them,  one  has  them  close 
their  eyes  and  then  asks  them  to  tell  what  objects  are  in  the  room. 

One  must  never  forget  to  obtain  a  clear  idea  of  the  attitude  of  the 
patient  toward  the  examination.  Some  errors  are  not  due  to  inability 
but  to  emotional  stupor,  indifference,  negativism,  and  ill  will.  Char- 
acteristic of  embarrassment  in  examinations  are  answers  in  which 
the  given  material  is  mixed  up,  as  when  in  figuring,  single  figures  in 
the  problem  are  put  into  the  answer,  etc. 

Moreover,  neither  in  the  diagnosis  nor  in  any  other  examination 
must  the  totality  of  the  objective  and  subjective  conditions  be  over- 
looked. In  the  complicated  psychic  mechanisms  the  identical  mani- 
festations have  under  different  circumstances  an  entirely  different 
significance.  Senseless  delusions  indicate  in  the  clear  average  patient 
an  existing  dementia,  but  not  in  the  oligophrenic,  or  in  the  delirious 
patient.  Somatic  hallucinations  only  when  accompanied  by  clear 
mindedness  are  sure  to  demonstrate  a  schizophrenia.  Catatonic  symp- 
toms in  acute  conditions  becloud  the  prognosis  little,  in  chronic  condi- 
tions they  have  a  bad  significance.  A  "rigid"  affect  may  indicate  an 
examination  stupor  or  schizophrenia.  "Negativism"  in  a  sensitive 
person  may  be  the  result  of  the  physician's  demeanor  or  of  some  other 
part  of  the  situation.     A  delirious  patient  with  whom  it  is  difficult  to 


THE  RECOGNITION  OF  INSANITY  191 

establish  a  relationship  is,  us  a  rule,  a  schizophrenic  or  he  has  epilepti- 
form attacks.  But  in  exceptional  cases  such  behavior  may  be  a 
symptom  of  a  light  delirium. 

Such  a  patient  who  for  the  three  days  showed  an  otherwise  typical 
alcoholic  delirium  turned  his  back  on  us,  gave  either  no  answer  or 
short,  rejecting  ones.  He  was  a  vagrant  of  rather  exaggerated 
joviality,  who  had  often  been  locked  up  for  trifles  and  considered  such 
measures  as  unjustifiable,  especially  too,  his  commitment  to  the  clinic 
because  they  had  lied  to  him  about  it.  In  the  mild  development  of 
the  delirium  he  was  conscious  of  these  circumstances,  and  on  account 
of  which  fact  he  later  explained  his  reaction. 

Some  psychic  symptoms  also  occur  in  diseases  which  we  do  not 
describe  here,  such  as  fevers,  traumata,  heart  diseases,  uremia, 
eclampsia,  and  similar  diseases.  What  is  still  more  important  is  this: 
one  must  never  expect  the  reverse,  namely  to  see  in  a  given  moment 
all  the  important  symptoms  of  a  disease.  One  must  never,  for  example, 
conclude  that  if  there  is  no  affective  disturbance,  therefore  it  is  not 
a  case  of  Schizophrenia.  Indeed  under  certain  circumstances  even  in 
a  pronounced  psychosis  one  can  temporarily  find  nothing  morbid.  A 
negative  finding  without  prolonged  observation,  therefore,  never  proves 
that  the  patient  is  normal;  it  only  indicates  an  absence  of  proof  of  the 
disease. 

Simulation  and  Dissimulation.  Simulation  of  insanity  is  not 
nearly  so  common  as  the  layman  supposes.  Those  who  simulate  in- 
sanity with  some  cleverness  are  nearly  all  psychopaths  and  some  are 
actually  insane.  Demonstration  of  simulation,  therefore,  does  not  at 
all  prove  that  the  patient  is  mentally  sound  and  responsible  for  his 
actions.  The  decision  as  to  whether  there  is  simulation  must  in  most 
cases  depend  on  the  evidence  of  the  absence  or  presence  of  inimitable 
symptoms.  Those  who  have  not  had  long  experience  in  hospitals  for 
the  insane,  and  present  a  consistent  morbid  picture,  rich  in  symptoms, 
are  not  resorting  to  simulation.  If  the  deception  is  not  readily  trans- 
parent, observation  in  an  asylum  must  be  required  in  order  to  '"un- 
mask" the  person. 

Simulation  is,  moreover,  proven  by  inconsistencies,  clumsy  exag- 
gerations, and  by  a  representation  of  a  morbid  picture,  that  exists  only 
in  the  layman's  imagination  (Beware  of  unconscious  simulation  as  in 
the  Ganser  and  buffoonery  syndromes,  puerilism,  etc.).  A  supposed 
insomnia  can  be  controlled  by  watching  the  patient  at  night.  Ex- 
citements that  entail  exertion  cannot  be  continued  very  long  because 
of  fatigue;  in  thrashing  about  with  or  without  convulsive  movements 
the  simulator  plainly  takes  care  not  to  hurt  himself,  etc.     One  can 


192  TEXTBOOK  OF  PSYCHIATRY 

also  suggest  that  this  or  that  symptom  that  belongs  to  the  disease  is 
lacking,  whereupon  the  simulator  usually  hastens  to  complete  the 
picture.  These  are  a  few  indications.  All  details  cannot  be  described, 
as  one  would  have  to  repeat  the  entire  symptomology  from  this  ^oint 
of  view.  A  very  thorough  uninterrupted  observation,  if  possible  both 
by  day  and  night,  is  important.  On  the  one  hand  this  will  tire  the 
simulator  and,  on  the  other,  it  will  usually  produce  many  evidences 
of  the  attempted  deception.  The  first  glance  often  arouses  a  suspicion 
of  simulation  when  one  notices  that  the  patient  who  has  just  been 
admitted  acts  in  an  excited  and  confused  manner  and  at  the  same 
time  attempts  to  orientate  himself  by  glancing  about  and  following 
carefully  everything  going  on  around  him. 

It  is  more  difiicult  to  judge  simple  exaggerations  in  psychopathic 
or  even  insane  people.  Here,  too,  the  line  of  demarkation  between 
conscious  simulation  and  disease  is  as  faint  as  in  the  case  where  the 
unconscious  acts  the  part,  e.g.,  in  the  Ganser  syndrome.  At  times, 
therefore,  one  cannot  decide  how  much  of  the  "simulation"  is  conscious 
deception  and  how  much  emerges  from  the  unconscious  as  a  product 
of  the  disease. 

Much  more  frequent  than  simulation  one  observes  dissimulation 
of  a  mental  disease.  Melancholies  make  it  appear  that  they  are  cured 
in  order  to  carry  out  suicide;  other  patients,  so  that  they  will  not  be 
limited  in  their  activities  or  to  obtain  an  opportunity  for  carrying  out 
their  plans,  etc.  This  dissimulation  on  the  patient's  part  is,  naturally, 
only  a  concealment  of  thoughts  and  symptoms  which  they  know  others 
regard  as  signs  of  insanity.  For  they  themselves  do  not  consider 
themselves  sick. 


CHAPTER  IX 

DIFFERENTIAL  DIAGNOSIS 

In  differentiating  the  psychoses  one  has  to  keep  in  mind  that  most 
of  the  individual  pictures  of  conditions  and  syndromes  may  occur  in 
different  diseases;  one  must  therefore  look  in  addition  to  these  for 
concomitant  specific  symptoms  and  for  specific  shades  of  the  syndrome. 
None  of  the  diseases  have  specific  symptoms  and  except  perhaps 
from  the  course  they  take,  they  should  therefore  be  diagnosed 
only  by  the  careful  exclusion  of  other  diseases  ("negative  diag- 
nosis"), such  as  manic  depressive  insanity,  paranoia,  hysteria,  com- 
pulsion neurosis,  and  the  psychopathic  conditions.  Specific  symp- 
toms of  amentia,  uremia,  and  many  other  rarer  diseases  are  not  yet 
known. 

In  the  differential  diagnosis  also  one  cannot  expect  to  find  at  any 
particular  moment  all  the  differentiating  characteristics;  and  there, 
too,  nearly  all  symptoms  are  to  be  valued  only  in  connection  with  the 
psychic  environment.  The  psyche  offers  so  many  possibilities  that 
through  a  chance  constellation  a  symptom  of  one  disease,  considered 
specific,  may  sometimes  be  imitated  by  another.  Our  language,  even, 
cannot  cope  with  the  wealth  of  manifestations  and  must  designate 
different  things  with  identical  or  similar  names;  the  pressure  activity 
in  mania,  in  presbyophrenia,  in  paretic  and  several  other  organic 
dehria,  and  that  in  delirium  tremens,  are  of  entirely  different  varieties 
and  cannot  be  differentiated  by  brief  designations.^  Whoever  follows 
diagnostic  catch  words  without  paying  attention  to  constellations  and 
nuances  will  go  wrong  any  moment.-  Also  the  diagnostic  observations 
in  the  special  part  of  this  book  make  no  claim  to  completeness  but 
emphasize  only  that  which  might  be  insufficiently  stressed  in  the 
symptomology  of  the  disease,  especially  in  the  diagnosis.  The  essen- 
tials for  the  diagnosis  must  be  gathered  from  a  knowledge  of  the  entire 
disease.  The  following  remarks,  too,  are  only  to  be  utilized  in  this 
sense. 

^  In  many  twilight  states,  too,  and  in  erethic  idiocy  there  are  syndromes  which 
could  be  called  pressure  activity. 
'  Cf .  also  footnote,  p.  84. 

193 


194  TEXTBOOK  OF  PSYCHIATRY 

COMPILATION  OF  THE  DIFFERENTIAL  DIAGNOSTIC 
SIGNIFICANCE  OF  INDIVIDUAL  SYMPTOMS 

Disturbances  of  Perception  ^ 

Sense  perception  is  retarded  and  often  falsified  in  the  organic 
psychoses,  and  in  a  very  similar  but  not  identical  sense  in  epilepsy; 
in  alcoholism  it  becomes  inexact,  but  no  retardation  is  seen  when  tested 
without  apparatus.  In  all  cloudings  of  consciousness  it  can  be  dis- 
turbed in  various  ways. 

In  jorms  of  idiocy  the  synthesis  of  combined  impressions  is  affected; 
the  patients  see  and  comprehend  the  unit  but  cannot  work  it  into  a 
complete  picture.  At  times  the  meaning  of  simple  pictures  is  not 
recognized,  even  perspective  is  not  understood. 

Real  illusions  may  occur  everywhere,  and  are  especially  prevalent 
in  clouding  of  consciousness. 

Of  the  hallucinations  those  referring  to  sight  usually  preponderate 
in  disturbances  of  consciousness  such  as  delirium,  twilight  states,  etc.; 
in  mental  clearness  they  are  rare. 

In  chronic  conditions  of  schizophrenia  accompanied  by  clearness 
auditory  and  somatic  hallucinations  predominate;  under  these  circum- 
stances the  latter  are  characteristic  of  the  disease.  Hallucinations 
and  illusions  of  smell  and  taste  occur  especially  in  schizophrenia,  but 
also  in  delirium  tremens,  and  in  various  twilight  states. 

Characteristic  of  delirium  tremens  are  in  the  first  place  tactile 
hallucinations,  then  the  numerous  visual  hallucinations,  which  are 
multiple,  moving,  and  mostly  colorless,  often  representing  particularly 
small  or  diminutive  objects,  especially  animals.  Along  with  visions 
of  this  sort  the  patients  frequently  feel  and  see  threadlike  objects, 
wires,  ropes,  spittle,  and  streams  of  water.  Auditory  hallucinations, 
in  pure  delirium  tremens,  have  noticeably  often  the  character  of 
music,  which  is  otherwise  rare.  If  verbal  auditory  hallucinations  are 
prominent,  it  is  a  question  of  complications,  especially  with  schizo- 
phrenia or  with  alcoholic  insanity. 

Auditory  hallucinations  of  a  dramatically  connected  character  that 
refer  to  the  patient  in  the  third  person  indicate  with  great  certainty 
abuse  of  alcohol  and  occur  in  acute  alcoholic  insanity  and  in  alcoholic 
schizophrenics. 

Microscopically  reduced  hallucinations  of  sight  and  touch  belong 
to  cocainism.     In  sniffing  cocainism,  one  frequently  observes  tangibly 
distinct  voices,  visual  illusions,  and  vividly  colored  visions. 
'  Cf .  also  p.  56. 


DIFFERENTIAL  DIAGNOSIS  195 

In  manic  depressive  and  in  organic  psychoses,  visual  and  auditory 
hallucinations  are  most  common.  In  organic  patients  they  are  much 
more  frequent  at  night  than  in  the  daytime. 

Visual  and  auditory  hallucinations  in  themselves  have  no  specific 
significance;  they  are  the  ones  that  may  occur  in  every  mental 
disturbance. 

Disturbances  of  Association 

Flight  of  ideas  occurs  in  the  different  manic  states,  at  times  in 
exhaustion,  otherwise  hardly  ever;  thus  in  epileptic  excitements  it  is 
extremely  rare. 

Inhibition  of  associations,  retardation  and  inability  to  rid  oneself 
of  a  sad  subject  which  may  run  to  monideism  is  a  partial  manifesta- 
tion of  the  various  depressive  states.  Other  form-s  of  retardation  of 
thought  may  occur  in  various  diseases  such  as  brain  pressure,  organic 
inertia,  and  toxic  states. 

In  schizophrenia  and  under  certain  circumstances  also  in  hysteria 
we  find  blockings  as  an  exaggeration  of  a  mechanism  that  occurs 
in  every  healthy  person;  moreover,  some  or  all  of  the  influences 
that  otherwise  guide  associations  are  often  lacking,  which  results 
partly  in  bizarre,  and  partly  in  entirely  disconnected  chains  of 
ideas. 

In  epilepsy  ideation  is  slow  and  hesitating,  the  mental  content  be- 
comes restricted  to  the  ego,  there  is  an  inclination  to  affective  colored 
associations  especially  to  those  containing  judgments  of  value,  and 
further  to  perseverations,  tautologies  and  to  circumstantiality  in  par- 
ticular; the  patients  do  not  easily  get  rid  of  a  subject  without  thinking 
it  out  in  many  directions. 

In  organic  conditions,  too,  there  is  a  tendency  to  perseveration  and 
there  is  frequently  a  retardation  of  all  reactions.  But  more  important 
is  the  restriction  of  the  number  of  ideas  simultaneously  possible. 
Especially  readily  absent  are  those  ideas  that  contradict  an  actual  pur- 
pose, whereby  organic  dementia  is  most  strikingly  characterized. 

In  oligophrenics  the  range  of  associations  is  also  limited ;  but  what 
is  lacking  belongs  to  the  complicated  associations,  the  attainment 
of  which  requires  a  higher  psychic  activity,  and  to  those  that  are 
extraordinary.  The  patient  thinks  of  what  is  plain,  tangible  and 
ordinary. 

In  paranoia,  and  in  a  certain  sense  in  hysteria  also,  some  associa- 
tions are  facilitated  and  others  are  inhibited,  according  to  whether 
or  not  they  harmonize  with  the  purposes  that  are  interwoven  with 
the  disease.    Aside  from  this  there  are  no  anomalies  of  association. 


196  TEXTBOOK  OF  PSYCHIATRY 

Disturbances  of  Orientation 

Orientation  as  to  place  and  time  is  disturbed  in  advanced  organic 
mental  diseases,  and  generally  in  delirious  and  twilight  states  of  all 
kinds.  In  schizophrenic  twilight  states  correct  orientation  often  exists 
with  the  falsified.  The  other  patients  know  where  they  are  and  what 
time  it  is,  unless  chance  circumstances  falsify  these  concepts. 

Orientation  as  to  situation  is  as  a  rule  naturally  also  incorrect  if 
place  and  time  are  registered  incorrectly;  but  in  addition  it  may  be 
disturbed  in  every  hindrance  to  judgment,  or  as  a  result  of  manic 
ideas  or  similar  anomalies. 

Autopsychic  orientation,  the  personality  with  its  relation  to  the 
family,  occupation,  dwelling  place,  etc.,  is  most  readily  falsified  in 
paresis  and  in  dreamlike  twilight  states.  It  is  striking  the  way  it 
remains  intact  in  the  deepest  delirium  tremens,  while  an  apparently 
sensible  paretic  or  a  schizophrenic  readily  declares  himself  to  be  the 
emperor  or  a  particular  saint. 

Disturbances  of  Memory 

In  chronic  alcoholism  the  memory  becomes  inexact;  katathymic 
memory  illusions,  whose  content  apparently  is  not  far  removed  from 
reality,  are  not  rare.  In  dementia  alcoholico-senilis  and  in  Korsa- 
koff's disease  there  is  also  an  organic  memory  disturbance.  After 
delirium  tremens  remembrance  is  incomplete  and  very  inexact;  after 
uncomplicated  acute  alcoholic  insanity  it  is  good.  After  pathologic 
drunkenness  there  is  usually  amnesia.  The  tendency  to  phantastic 
stories  is  heightened  in  delirium  tremens  to  confabulation-like  excuses, 
and  to  real  confabulations. 

The  memory  of  the  organic  group  is  characterized  by  an  especially 
marked,  or  exclusive  confusion  of  the  more  recent  memories.  The 
void  is  often  filled  by  provoked  (perplexity),  or  spontaneous  confabu- 
lations. Amnesias  after  dehria,  and  confusions  are  not  rare  even 
after  mere  excitements. 

The  schizophrenic  memory  retains  all  experiences;  but  blockings 
and  other  affective  reactions  in  a  given  moment  very  often  make  it 
impossible  for  the  patient  to  utilize  his  engrams.  As  there  is  no  elabo- 
ration of  perceptions  in  certain  chronic  stages,  the  schizophrenic 
memory  often  retains  insignificant  details  better  than  does  the  normal 
memory.  Memory  hallucinations  and  katathymic  illusions  are 
frequent.  In  spite  of  the  frequent  occurrence  of  deliria  and' 
twilight  states  amnesias  are  rather  rare,  and  still  more  rarely  are  they 
complete. 


DIFFERENTIAL  DIAGNOSIS  •    197 

In  epilepsy  the  memory  becomes  unsystematically  poor.  Complete 
or  partial  amnesia  is  an  ordinary  occurrence  after  twilight  states. 

Hysteria  at  times  very  markedly  transforms  memories  in  accord- 
ance with  the  momentary  affective  requirements.  After  twilight  states 
amnesia  is  apt  to  be  complete,  but  it  is  relatively  easy  to  remove  it 
by  suggestive  influences. 

In  the  paranoiac,  memory  illusions,  combined  with  the  morbid  self- 
reference,  form  the  most  important  foundation  of  the  delusions. 

In  oligophrenics  memory  varies  greatly.  All  things  being  equal, 
the  incomprehensible  is  naturally  retained  less  readily  than  the  com- 
prehensible, and  the  patients  understand  poorly  the  very  things  that 
appear  interesting  to  the  normal;  but  hand  in  hand  with  this  there 
is  often  a  noticeably  good  reproduction  of  unelaborated  material. 

In  conditions  of  melancholia  the  past  life  is  readily  explored  for 
sins.  Small  errors  are  transformed  into  unpardonable  crimes;  if 
none  are  found,  they  are  invented  as  a  sort  of  memory  hallucination 
or  memory  illusion. 

Even  during  manic  conditions  but  very  noticeably  after  them,  the 
morbid  behavior  of  the  patient  is  later  readily  justified  through  trans- 
formations in  the  memory  and  by  putting  the  blame  on  the  environ- 
ment. During  and  after  confusions  seldom  accompanied  by  flight  of 
ideas,  the  memory  is  very  incomplete. 

Amnesias  are  to  be  expected  after  all  disturbances  of  consciousness 
and  after  transitory  psychoses  generally,  that  is,  after  hysterical  and 
epileptic  attacks  and  twilight  states,  confusions  of  all  kinds,  toxemias, 
especially  drunkenness.  After  similar  conditions  of  schizophrenia  (twi- 
light states,  hallucinatory  states  with  dreamlike  episodes),  memor\'  is 
not  always  defective  and  when  it  is,  it  is  usually  only  partly  so. 

Amnesias  as  to  content  referring  to  events,  the  recollection  of  which 
is  at  the  time  disagreeable,  are  frequent  in  schizophrenia  and  hysteria. 

Affective  Disturbances 

The  affectivity  is  labile  in  organic  patients,  in  alcoholism,  in  hys- 
teria, and  in  the  later  intervals  of  many  manic  depressive  cases. 

Acute  displacement  of  the  affective  attitude  (moods)  in  the  sense 
of  manic  or  melancholic  appearances  is  seen  in  alcoholism,  in  the  rather 
uncommon  alcoholic  melancholia,  in  organic  psychoses,  in  schizo- 
phrenia (very  common),  in  epilepsy  which  is  of  brief  duration  and 
also  shows  the  very  common  irritable  depression,  in  manic  depressive 
insanity,  in  hysteria,  in  all  kinds  of  psychopathic  states,  especially  in 
the  cyclothymias,  and  in  oligophrenics  w^iere  it  is  as  a  rule  of  short 
duration  and  often  manifests  irritable  moods. 


198  TEXTBOOK  OF  PSYCHIATRY 

The  organic  affective  disturbances  regularly  show  lability,  acces- 
sory moods,  which  are  preponderatingly  manic  in  paresis  and  melan- 
cholia, especially  in  the  senile  forms.  In  alcoholic  Korsakoff's  dis- 
ease besides  lability,  there  usually  is  also  a  euphoric  basal  mood,  which 
is  not  apt  to  disappear  until  the  later  stages  of  crossness  and  irritation. 

In  schizophrenia  the  affects  cease  to  function  altogether  in  severe 
cases;  in  milder  cases  affective  reactions  sometimes  appear  and  some- 
times not;  when  they  are  present,  they  are  often  rigid.  At  times 
they  are  absent  just  at  the  most  important  events,  whereas  trifles 
are  normally  accentuated.  In  many  cases  irritation  up  to  the  stage 
of  unbounded  rage  is  the  only  reaction  which  one  sees  for  a  long  time; 
in  mild  cases  irritation  may  be  the  only  striking  symptom.  Para- 
thymia and  paramimia  are  not  infrequent.  Ambivalence  is  nowhere 
so  conspicuous  as  in  schizophrenia.  Besides  these,  one  also  sees  mel- 
ancholic and  manic  affective  fluctuations. 

In  the  epileptic  the  affects  are  easily  stirred,  readily  attain  an 
abnormal  intensity  but  last  abnormally  long.  At  the  same  time  they 
are  massive  and  not  finely  differentiated.  Fitful  moods  of  an  ir- 
ritated, depressive  or  euphoric  character  are  probably  never  lacking. 

The  manic  depressive  patient  in  the  interval  between  manic 
or  depressive  attacks  often  has  lability  of  the  affects  or  lasting  states 
in  the  sense  of  milder  manic  or  melancholic  moods. 

In  hysteria  one  sees  slight  outbreaks  during  which  there  is  heighten- 
ing and  falling  off  of  the  affects.  Reactions  to  similar  stimuli  are 
quantitatively  and  also  qualitatively  different,  depending  on  chance 
intervention. 

In  paranoia  the  affective  state  corresponds  to  the  content  of  the 
real  or  delusional  experiences.  The  affective  anomalies  that  must  lie 
at  the  root  of  the  disease  cannot  yet  be  described  more  minutely. 

Among  oligophrenics  there  are  excitable  and  torpid  types;  briefly 
all  the  variations  occur  that  we  see  in  normal  and  psychopathic  per- 
sons, and  only  when  possible  they  run  within  wider  limits.  Besides, 
many  cases  evince  the  same  moods  as  epileptics. 

In  all  forms  of  dementia  there  is  a  tendency  to  outbursts  of  anger. 

Some  Special  Syndromes 

States  of  stupor  occur  most  frequently  in  schizophrenia,  next  in 
epilepsy,  hysteria,  and  besides  in  melancholic  states,  in  the  mixed 
states  of  manic  depressive  insanity,  and  in  paresis. 

Tivilight  states  are  seen  in  epilepsy,  hysteria  and  in  schizophrenia, 
occasionally  perhaps  in  manic  depressive  insanity,  then  in  the  various 
toxic  states  (as  in  the  pathologic  drunkenness),  in  states  of  ordinary 


DIFFERENTIAL  DIAGNOSIS  199 

sleep  (somnambulism,  etc.),  following  cerebral  concussions  and  hang- 
ing, in  very  severe  migraines,  and  even  as  states  of  excitement  of 
purely  affective  origin  in  psychopaths  (jail  outbursts,  fugues,  etc.). 

Symptoms  of  the  Catatonic  type.  Symptoms  which  from  their 
external  appearance  must  be  designated  as  catatonic,"*  besides  oc- 
curring in  schizophrenia  appear  also  in  the  organic  psychoses;  further- 
more catalepsy  is  not  rare  in  epilepsy  and  is  also  said  to  have  been 
noticed  occasionally  in  hysterical  twilight  states,  in  oligophrenia,  and 
in  manic  depressive  insanity.  Something,  that  must  be  called  echolalia 
in  spite  of  an  apparently  very  different  origin,  besides  occurring  in 
schizophrenia  and  the  organic  psychoses  (very  rarely)  appears  also 
in  epilepsy,  hysteria,  and  oligophrenia. 

Epileptiform  attacks,  besides  occurring  in  the  epilepsies  appear  in 
schizophrenia,  paresis,  presbyophrenia,  some  forms  of  arteriosclerosis, 
alcoholism,  including  delirium  tremens,  as  affective  epilepsy  in  psycho- 
pathies, and  outside  of  psychiatry,  in  all  coarse  cerebral  diseases,  in 
uremia  and  eclampsia. 

Paretic-like  attacks  occur  in  all  coarse  brain  diseases,  especially 
when  they  involve  the  cortex. 

Compulsive  ideas  and  eventually  compulsive  impulses  we  see  rather 
frequently  besides  in  the  independently  considered  compulsion  neurosis 
and  compulsion  psychosis,  also  in  schizophrenia,  but  pretty  rarely  in 
the  various  depressive  states. 

Uremia  may  also  simulate  the  psychic  symptoms  as  well  as  most 
physical  symptoms  of  an  organic  brain  disease  or  of  epilepsy. 
Eclampsia,  too,  may  for  a  short  time  act  exactly  like  epilepsy. 

*  Cf .  p.  153. 


CHAPTER  X 

CAUSES  OF  MENTAL  DISEASES 

I.  Germinal  Predisposition.  It  was  always  known  that  mental 
diseases  converge  in  one  family  and  lack  in  another,  and  that  in  the 
families  with  mental  diseases  the  members  that  are  not  really  dis- 
eased very  frequently  show  certain  deviations,  which  often  run  in  the 
direction  of  the  disease.  To  be  sure  those  families  are  rare  which  on 
careful  search  prove  entirely  free,  and  the  cases  with  only  a  few 
diseased  members  are  always  the  more  common.  Nevertheless  the 
family  predisposition  is  surely  one  of  the  most  important  deter- 
minants for  the  development  of  mental  diseases.^  To  be  sure  a  pre- 
disposition alone  need  not  find  expression  in  disease,  even  when  it 
undoubtedly  shows  itself  in  the  particular  individual  through  minor 
deviations  from  the  normal  and  through  transference  to  the  descend- 
ants. Either  there  are  different  grades  of  hereditary  predisposition 
or  the  predisposition  does  not  "develop"  in  all  into  a  pronounced 
disease,  or  both  cases  may  occur.  Besides,  we  have  to  presuppose 
some  predispositions  which  in  themselves  are  not  diseased  but  still 
form  necessary  or  at  least  furthering  determinants  in  the  development 
of  exogenous  diseases:  Not  every  inebriate  becomes  a  "psychic" 
alcoholic  and  not  every  luetic  becomes  paretic;  but  certain  psychic 
peculiarities  that  are  discoverable  in  most  candidates  for  alcoholism 
and  paresis  and  their  families  indicate  that  inherited  factors  play 
a  role  even  in  exogenous  diseases. 

Formerly  it  was  necessary  to  assume  a  general  neuro-  and  psycho- 
pathic family  predisposition  that  might  express  itself  in  the  most 
variegated  nervous  and  mental  diseases  and  psychical  peculiarities. 
But  since  KraepeUn  taught  us  to  recognize  natural  boundaries  be- 
tween several  clinical  pictures,  the  concept  of  psychotic  heredity  be- 
gan to  be  more  and  more  clearly  divided  into  several  predispositions, 
among  which  may  be  mentioned  in  the  first  place  the  big  groups  of 
schizophrenias,  epilepsies  and  manic  depressive  insanity.     A  part  of 

^  The  conspicuous  significance  of  predisposition  shows  itself  especially  in  the 
insanity  oj  twim  where  occasionally  both  members  become  sick  at  the  same  time 
and  with  very  similar  symptoms,  and  what  is  more,  that  may  happen  even  when 
they  do  not  live  together. 

200 


CAUSES  OF  MENTAL  DISEASES  201 

the  psychopathies  as  well  as  most  of  the  neuroses  proved  tcj  be  the 
lighter  and  simpler  forms  of  these  hereditary-  groups. 

Very  recently  the  attempt  was  made  to  apply  the  Mendelian  laws 
to  the  hereditary  mental  diseases  and  endeavor  to  make  it  probable 
that  these  are  transmitted  recessively  according  to  the  Mendelian 
type.  But  the  theoretical  and  practical  difficulties  are  far  too  great 
to  have  produced  something  useful  so  far.  We  are  far  from  under- 
standing what  is  involved.  With  the  endless  shades  of  morbid  pre- 
dispositions, from  the  slight  peculiarity  of  character  up  to  the  most 
pronounced  insanity,  it  is  out  of  the  question  that  the  predisposition 
to  a  psychosis  or  even  the  disease  itself  should  be  a  plain  indication 
that  can  be  present  or  absent  only  as  a  whole;  we  would  rather  say 
that  at  present  we  cannot  dispense  with  the  assumption  of  a 
mechanism,  which  may  be  provisionally  designated  as  "intermediary 
heredity."  ^  Furthermore  the  small  number  of  children  and  the  long 
duration  of  a  generation  increase  the  difficulties  of  the  survey  in 
these  studies  to  a  particularly  high  degree. 

Besides  these  lasting  family  predispositions  "Degenerations"  are 
spoken  of.  The  term  designates  very  different  but  very  vague  ideas, 
and  most  observers  are  so  little  conscious  of  this  that  they  do  not  at 
all  express  themselves  about  it,  but  secretly  permit  one  meaning  to 
pass  over  into  the  other,  or  suddenly  substitute  one  for  the  other. 
These  concepts  may  be  arranged  into  four  classes,  two  relating  to  the 
family,  and  two  to  the  individual: 

1.  It  is  assumed  that  some  families  degenerate  through  the  differ- 
ent generations,  that  they  become  more  and  more  incapacitated  and 
generate  severer  forms  of  mental  diseases,  until  they  die  out.  Morel 
even  supposed  that  this  occurs  so  regularly  that  it  was  possible  to 
prognosticate  definite  diseases  for  each  of  the  last  four  generations. 
As  a  matter  of  fact  there  is  really  no  such  regularity  and  we  cannot 
say  anything  worth  while  either  about  degeneration  or  regeneration. 
Furthermore  the  Mendelian  conceptions  which  are  clear  and  hold  good 
for  certain  conditions  present  an  insurmountable  opposition  to  such 
views.  In  more  recent  times  morbid  predispositions  were  progressively 
(not  regularly)  produced,  throughout  generations,  by  means  of  poisons. 

2.  It  has  also  been  customary  for  some  time,  regardless  of  the 
progressi"'-eness  of  the  predisposition,  to  designate  families  in  which 
insanities  are  very  common,  as  degenerate,  especially  if  the  healthy 
members  also  show  striking  peculiarities. 

3.  Depending  somewhat  on  this  concept,  constitutional  peculiarities 

'  Bleuler,   Mendelismus  b.  Psychosen  spez.   bei   der  Schizophrenia.   Sheweiz. 
Arch.  f.  Neurologie  und  Psychiatric.    Vol.  I.    Ziirich  1917. 


202  TEXTBOOK  OF  PSYCHIATRY 

in  the  individual  are  designated  as  "degenerative,"  in  which  case 
usually  the  impression  is  made  as  if  a  definite  concept  were  being 
used.  But  actually  the  most  different  deviations  from  the  normal  in 
all  directions  are  so  designated,  provided  they  are  not  included  in 
one  of  the  familiar  morbid  pictures.  In  this  sense  all  families  bur- 
dened with  heredity  and  their  individual  (abnormal)  members  are 
degenerates.^ 

4.  There  are  also  degenerative  psychoses  that  are  again  divided 
into  two  very  different  classes:  (a)  those  that  show  the  characteristics 
described  in  classes  2  and  3,  that  develop,  or  are  supposed  to  de- 
velop from  an  abnormal  constitution  (Paranoia,  "periodic  forms"), 
or  where  serious  peculiarities  of  character  are  observable  as  causes 
or  concomitant  of  the  "real"  morbid  picture  (degenerative  hysteria), 
(b)  Such  diseases  as  have  the  tendency  to  "degenerate"  i.e.  they 
show  a  tendency  gradually  to  become  worse,  to  degenerate  into  de- 
mentia as  seen  in  our  schizophrenias  so  far  as  they  really  merge  into 
idiocy. 

One  should  avoid  working  with  such  an  ambiguous  conception  as 
degeneration  and  its  designation.  The  concept  of  degeneration  would 
most  readily  fit  blastophthoric  conditions,  the  most  marked  develop- 
ments of  which  we  call  teratologic,  and  the  milder  forms  perhaps 
might  include  all  kinds  of  predispositions  even  those  of  psychoses. 
Families  with  many  abnormal  members  like  those  abnormal  in- 
dividuals mentioned  in  class  3  we  call  psychopathic;  those  with  a 
tendency  to  definite  mental  diseases  like  those  mentioned  in  class  i, 
or  with  less  pronounced  peculiarities  in  the  sense  of  a  psychosis  we 
name  accordingly  manic  depressive,  schizoid,  or  epileptoid  families. 

Race  is  an  important  consideration  for  the  origin  as  well  as  for 
the  formation  of  the  diseases,  even  though  at  present  we  know  very 
little  that  is  definite  about  it.  The  great  number  of  insane  we  find 
in  the  present  culture  races;  but  whether,  and  to  what  extent,  more 
insanity  occurs,  or  more  remain  alive,  and  how  much  the  damaging 
influence  of  natural  selection  amounts  to,  has  not  yet  been  investi- 
gated. Many  peoples,  notably  North  Africans,  Abyssinians,  South 
Slavs,  Turks,  and  Australian  aborigines,  are  entirely  or  to  a  high  degree 
immune  to  paresis,  although  syphilis  is  common  among  them.  Still 
our  ancestors  more  than  four  generations  ago  were  also  apparently 
immune  and,  on  the  other  hand,  the  Japanese  who  are  far  less 
closely  related  to  us  are  now  as  subject  to  paresis  as  we.  The  more 
or  less  extensive  use  of  alcohol  does  not  explain  all  these  differences. 
Dementia  precox,  epilepsy  and  idiocies  also  seem  to  occur  in  lower 

'  Magnan's  idea  of  degeneration  is  a  combination  of  2  and  3. 


CAUSES  OF  MENTAL  DISEASES  203 

races  as  with  us,  the  first,  to  be  sure,  in  somewhat  different  forms. 
Kraepelin  observed  among  the  Malays  an  absence  of  the  catatonic 
forms;  I  could  ascertain  the  same  among  negroes  and  Indians  as 
far  as  modes  of  appearances  are  concerned  that  could  be  observed 
as  pronounced  catatonias  on  just  walking  through  institutions  and 
in  questioning  physicians  and  head  nurses.  The  same  may  be  said 
here  of  suicide,  whereas  just  the  Germanic  race  and  especially  the 
Saxons  are  very  frequently  victims  of  suicide.  It  is  said  that  Jews 
are  especially  predisposed  to  manic  depressive  insanity  and  psycho- 
neuroses.  According  to  a  very  experienced  older  psychiatrist  they 
did  not  develop  paresis  until  they  took  to  "Christian  customs  and 
Christian  champagne";  in  general,  race  and  manner  of  living,  that  is  to 
say  culture,  are  difficult  to  separate.* 

II.  Blastophthory.  It  seems  that  even  with  sound  parental  pre- 
disposition the  germ  may  be  so  damaged  in  its  development  that  the 
descendant  becomes  (mentally)  diseased.  Such  influences  are  ascribed 
especially  to  debilitating  diseases,  poisons  (alcohol!),  and  infections. 
But  in  the  last,  among  which  syphilis  comes  into  prominent  con- 
sideration, one  cannot  properly  separate  the  transference  of  the  dis- 
ease to  the  child  from  the  germinal  damage.  In  this  field  many 
assumptions  are  opposed  by  a  few  definite  facts. 

III.  Germ  Fusion.  There  are  a  few  cases  that  seem  to  prove  that 
an  unsuitable  fusion  of  healthy  germs  ("germinal  enmity")  can  gen- 
erate diseases;  thus  a  couple  produced  only  microcephalics,  while 
each  of  the  individual  parents  had  healthy  children  with  another 
mate.  Also  marked  differences  in  the  character  predispositions  of 
the  parents  make  themselves  felt,  according  to  all  we  know,  in  a  cer- 
tain lack  of  equilibrium  in  the  descendants.  To  be  sure,  in  individual 
cases  this  may  become  the  foundation  of,  and  the  impulse  to.  great 
achievements,  especially  the  artistic;  generally  it  is  nevertheless  an 
unpleasant  supplement  to  life  and  one  that  readily  erupts  into  the 
neurotic.  The  intermingling  of  races,  even  those  closely  related, 
often  has  still  worse  results  although,  at  least  according  to  superficial 
observations  of  masses,  the  West  Indian  negroes,  in  whom  a  white 
streak  is  easily  noticed,  are  a  tribe  so  capable  of  enjoying  life  and 
so  unburdened  with  any  sense  of  responsibility  that  one  may  well 
ask  whether  it  is  not  we  who  constitute  the  unsuccessful  variety  of 
humanity. 

Relationship  between  parents  (inbreeding)  is  also  much  feared. 
But  it  turns  out  that,  in  spite  of  the  experience  of  animal  breeders, 
who  have  to  reckon  with  many  more  generations,  that  under  human 

*See  below,  American  Negroes. 


204  TEXTBOOK  OF  PSYCHIATRY 

conditions  injury  through  intermarriages  is  not  demonstrable  unless 
there  is  a  summation  of  a  common  predisposition  to  disease  in  the 
vulgar  sense,  or  a  cumulation  in  the  Mendelian  sense.  In  Incas,  the 
Pharoahs,  the  Ptolemys,  propagated  themselves  through  numerous 
generations  by  marriages  between  brother  and  sister,  and  an  inter- 
marriage within  a  healthy  family  in  every  event  offers  better  chances 
than  the  intermingling  of  doubtful  or  perhaps  diseased  foreign  blood. 
Nevertheless,  in  view  of  the  many  cases  of  deaf  mutism  and 
of  optic  atrophy  observed  in  intermarriages  as  well  as  the  experi- 
ences with  animal  breeding  it  behooves  one  to  observe  a  certain 
caution. 

IV.  Foetal  Diseases.  The  embryo,  too,  may  be  harmed  by  dis- 
eases of  the  mother,  lack  of  room  in  the  pelvis,  by  traumatic  occur- 
rences, as  well  as  by  intrauterine  diseases,  so  that  it  comes  into  the 
world  as  an  idiot  or  psychopath.  To  what  extent  psychical  influences 
on  the  mother  harm  the  foetus,  has  not  been  scientifically  determined. 
Undoubtedly  sorrow  and  other  chronic  depressions  may  disturb  nutri- 
tion; and  a  psychic  shock — perhaps  through  a  spasm  of  the  uterine 
vessels — may  be  noticed  by  the  foetus  to  such  an  extent  that  it  may 
find  a  vent  in  wild  movements  with  change  of  position  whereby  in- 
juries of  various  kinds  are  conceivable. 

The  categories  I  to  IV  are  often  designated  as  "endogenous  causes.'^ 
But  only  I,  the  pathological  germ  predisposition,  is  really  endogenous; 
the  remaining,  at  least  in  relation  to  the  family,  are  exogenous,  and 
in  relation  to  the  individual  they  may  be  called  what  one  pleases. 
In  studies  of  heredity  all  four  categories  were  hitherto  usually  thrown 
together.  It  is  very  important  for  future  research  that  this  should 
no  longer  be  done. 

If  all  people  were  designated  as  "burdened"  who  have  among  their 
blood  relations  (parents,  grand-parents,  children,  brothers  and  sisters, 
aunts  and  uncles)  members  who  suffer  from  mental  or  nervous  diseases, 
alcoholism,  apoplex>%  abnormal  character  or  have  committed  suicide, 
then  according  to  Diem  ^  67%  of  the  healthy  and  78%  of  the  insane 
who  are  admitted  to  institutions  are  burdened.  But  the  difference  be- 
comes greater,  if  one  counts  only  those  burdened  with  insanity 
(7:  38%)  or  with  abnormal  characters  (10:  15%)  and  still  greater,  if 
these  categories  are  supplied  merely  to  the  direct  burdening  (through 
the  parents),  since  only  2%  of  the  healthy  have  insane  parents  as 
against  18%  of  those  who  are  mentally  diseased,  and  6%  abnormal 
characters  against  13%.    Apoplexies  and  nervous  diseases  are  observed 

"  Die    psychoneurotische    Belastung    der    Geistesgesunden    und    der    Geistes- 
kranken,  Arehiv.  fiir  Rassen-und  Gesellschaftsbiologie  1905. 


CAUSES  OF  MENTAL  DISEASES  205 

less  frequently  in  the  families  of  the  insane  than  in  those  who  are 
healthy. 

Nowadays  heredity  is  talked  about  too  much,  although  in  prac- 
tical affairs  it  is  not  often  considered.  Many  people  actually  make 
life  hard  for  themselves  because  on  account  of  a  hereditary  burden 
they  are  afraid  of  getting  sick  or  being  sick.  As  a  matter  of  fact, 
families  in  which  the  majority  of  the  members  are  sick  are  rare. 
Furthermore  a  sort  of  regeneration  is  possible,  even  though  we  do  not 
feel  at  all  clear  about  this  term,  and  above  all  the  difference  between 
those  considered  burdened  and  those  considered  healthy  is  not  so 
great,  because  on  careful  examination  abnormalities  are  generally  to 
be  found  also  in  the  latter.  It  should  not  be  forgotten,  also,  that  many 
diseases  have  no  hereditary  significance,  as  for  instance  most  acquired 
forms  of  idiocy  and  paresis.  Furthermore,  a  sick  member  of  an  other- 
wise healthy  family  is  usually  less  dangerous  even  as  a  patient  than 
a  relatively  sound  member  of  an  otherwise  heavily  afflicted  family. 
In  the  former  case  the  exception  may  be  determined  by  an  acquired 
disease,  in  the  latter  it  may  represent  a  chance  aberration  upwards; 
both  variations  are  not  true  to  kind.  For  questions  of  eugenics 
Forel  described  the  risk  as  follows:  that  a  family  in  which  in- 
sanities occur,  but  which  in  spite  of  this  maintains  itself,  is  not  to  be 
feared;  while  members  of  a  declining  family  should  not  marry  or  be 
married. 

V.  The  exog-enous  causes  affecting  the  individual  sometimes 
create  disposition,  sometimes  they  precipitate  the  disease  either  as  a 
necessary  consequence  (carbon  monoxide)  or  as  the  cause  (psychic 
reasons),  or  as  one  of  the  various  necessary  conditions  of  the  disease 
(sypKilis  in  paresis).  It  is  furthermore  to  be  kept  in  mind  that 
while  individual  causes  frequently  produce  definite  morbid  pictures, 
(e.g.  traumatic  neuroses;  alcoholism,  paresis)  nevertheless,  depend- 
ing on  the  disposition  and  the  constellation  of  other  contributing 
conditions,  the  identical  (major)  causes  may  generate  and  occasion 
different  morbid  pictures,  such  as  different  traumatic  neuroses,  hysteria 
and  neurasthenia  in  certain  conflicts,  and  various  alcoholic  forms.  The 
same  psychic  influence  may  release  a  schizophrenic  attack  in  one  per- 
son, a  neurosis  in  another,  a  manic  attack  in  a  third.  Furthermore, 
depending  on  the  disposition  the  cause  may  be  indifferent,  thus  a 
woman  predisposed  to  cyclothymia  can  become  manic  through  a 
psychic  influence  or  through  a  childbirth,  and  the  epileptic  disposition 
can  probably  be  developed  into  pronounced  epilepsy  just  as  well 
by  a  trauma  as  by  alcoholic  poisoning.  It  can  be  seen  from  the 
illustrations  that  no  decided  distinction  is  to  be  made  between  causa- 


206  TEXTBOOK  OF  PSYCHIATRY 

live  and  merely  precipitating  conditions ;  but  we  must  understand  that 
it  is  a  different  matter  when  a  fright  neurosis  or  carbonic  oxide 
poisoning  develops  in  a  healthy  person  than  when  the  disease  becomes 
"manifest"  through  a  psychic  influence,  in  a  latent  schizophrenic  or 
manic  depressive  patient.  But  intermediate  cases  make  it  impossible 
to  carry  out  a  sharp  separation. 

Among  the  exogenous  causes  discontinuation  of  soothing  with  the 
natural  nourishment  is  to  be  mentioned  also,*^  although  here,  too,  we 
should  like  to  know  something  more  definite. 

Moreover  all  diseases  are  to  be  considered  that  directly  affect  the 
brain,  such  as  traumata,  and  in  childhood  above  all  polioencephalitis 
and  meningitis,  which  create  oligophrenias,  psychopathies,  epilepsies, 
and  organic  diseases.  Scleroses,  tumors,  and  other  brain  diseases 
cause  different  pictures.  Infectious  diseases  may  change  the  anatomical 
consistency  of  the  brain,  as  cerebral  lues,  paresis,  encephalitides,  and 
lyssa,  or  they  may  affect  its  function  through  poisoning  as  in  fever 
psychoses,  and  in  the  forms  of  "delirium  acutum,"  or  they  may  in- 
directly disturb  its  nutrition  as  in  syphilitic  diseases  of  the  blood 
vessels.  Besides  the  fever  psychoses,  infectious  diseases  can  probably 
precipitate  schizophrenic   "shifts." 

Other  physical  diseases  which  in  respect  to  the  brain  may  be  called 
exogenous  not  seldom  cause  mental  diseases;  carcinomatous  dyscrasia 
and  perhaps  stomach  and  bowel  disturbances  can  also  produce  states 
of  confusion;  diabetes  seems  to  favor  depressions;  through  the  neuritic 
processes  in  the  brain  it  can  bring  about  Korsakoff's  syndrome,  and 
through  acetone  poisoning  delirious  conditions.  Of  course,  diabetes 
is  also  frequently  only  a  parallel  manifestation  of  the  mental  disease, 
e.g.  in  organic  brain  diseases.  Hypo-function  of  the  thyroid  gland 
causes  myxedema  and  cretinism;  a  certain  complicated  hyper-func- 
tion causes  Basedow's  psychoses.  The  other  glands  are  also  connected 
with  the  psychic,  but  they  are  very  far  from  being  suflBciently 
understood. 

Of  the  external  poisons  alcohol  is  to  be  particularly  mentioned.  It 
is  responsible  for  20  to  35%  of  the  male  admissions  to  the  hospitals, 
and  probably  makes  alcoholics  of  10%  of  the  men  outside,'^  but  it  also 
complicates,  co-determines,  or  aggravates  other  psychoses,  especially 
epilepsy,  traumatic  neuroses,  and  paresis.^  A  similar  even  though 
numerically  a  vastly  minor  role  is  played  by  ether,  opium,  morphine, 

*  Bunge,  Die  zunehmende  Unfahigkeit  der  Frauen,  ihre  Kinder  zu  stillen.  7. 
Aufl.   Rheinhard,  Miinchen   1914. 

'  Schweizerische  Statistiks.  Sanitarisch-demographisches  Wochenbulletin,  1903, 
und  Internationale  Monatschrift  zur  Bekaempfung  der  Triiiksitten,  1904,  p.  183 

'The  influence  on  posterity  was  discussed  in  Part  II. 


CAUSES  OF  MENTAL  DISEASES  207 

and  cocaine.''  Other  poisons  that  enter  into  consideration  here  are 
lead,  carbon  monoxide,  pellagra  and  ergotine.  Sonie  also  wish  to 
blame  here  tobacco,  which  is  probably  an  unjust  view.  Lack  of  vita- 
mines  acts  like  the  poisons,  as  in  the  case  of  Beri-beri. 

Among  other  diseases  those  of  the  sense  organs,  especially  that 
of  hearing,  are  to  be  mentioned ;  the  latter  do  harm  rather  through  their 
psychic  influence.  Thus  paranoid  distrust  and  irritability  result  from 
defective  hearing,  heart  and  vascular  diseases  occasion  anxiety  states 
and  atrophies  of  the  brain,  while  kidney  diseases  are  often  at  the 
foundation  of  amentia. 

Exhaustion  ^°  also  is  said  to  produce  insanities ;  there  is  no  doubt 
that  hunger  in  its  last  stages  causes  deliria.  That  over-work,  which 
is  frequently  mentioned  may  bring  on  mental  diseases,  is  not  to  be 
assumed;  it  usually  conceals  politely  our  ignorance  of  the  causes, — 
a  good  physician  works  much  more  than  most  of  the  patients  that  come 
to  him  because  of  over-work.  It  is  more  proper  to  assume  that  the 
congenital  "morbid  exhaustiblity"  expresses  the  predisposition  to 
psychoses.  But  usually  it  is  emotional  difficulties  that  "exhaust  the 
nervous  energies,"  or  the  slowly  advancing  schizophrenia  deludes  the 
patient  with  a  feeling  of  exertion  and  over-exertion.  Among  ten  thou- 
sand Serbs  captured  in  the  late  war,  who  were  all  subjected  to  the 
most  miserable  state  of  maximum  over-exertion  and  severe  under- 
nourishment, only  five  became  insane.  Therefore,  acute  physical 
exhaustion,  _at  least,  may  be  crossed  off  the  list  of  the  causes  of 
psychoses.  Weakness  from  acute  loss  of  blood  is  also  not  a  cause  of 
psychoses,  according  to  statements  that  I  have  received  from  surgeons. 

Among  living  conditions  climate  should  be  mentioned;  but  as  yet 
we  do  not  know  its  influences.  Concerning  the  so-called  Tropical 
mania  which  is  naturally  a  collective  term  for  different  things,  it  is 
not  even  certain  to  what  extent  it  is  really  brought  on  merely  by 
the  heat,  and  to  what  extent  by  the  use  of  alcohol  and  by  other 
diseases,  and  by  the  feeling  of  being  absolute  master  of  life  and  death 
among  savages  (a  sort  of  Caesar  mania). 

Occupation  may  cause  poisoning,  thus  employees  of  the  alcohol 
industry  readily  become  alcoholics,  and  persons  occupied  with  the 
healing  art  become  morphine  addicts.  In  the  army  many  psychopaths 
succumb  to  disease  less  from  exertion  than  from  psychic  causes.  Some 
occupations,  such  as  school  teaching  and  acting,  are  said  to  dispose 

'  Most  recently  the  use  of  cocaine  in  the  form  of  snuff  powders  is  ver>- 
rapidly  gaining  the  ascendencj'  with  the  demi-monde  and  its  associates. 

"According  to  Kraepelin  exhaustion  is  the  excessive  consumption  or  insuf- 
ficient replacement  of  the  active  substances,  while  fatigue  is  the  accumulation 
of  waste  matter  that  has  a  paralyzing  effect. 


208  TEXTBOOK  OF  PSYCHIATRY 

people  to  mental  diseases.  But  what  is  more  likely  to  be  the  case  is, 
that  affected  or  rather  psychopathic  people  show  a  preference  for 
certain  callings,  just  as  no  occupation  or  tramping  is  selected  only 
by  morbid  or  insane  individuals. 

According  to  the  classification  of  civil  conditions  there  are  a  great 
many  single  persons  among  the  insane,  and  it  is  plausible  that  the 
more  regular  life  of  the  married,  in  sexual  and  other  respects,  is  a 
slight  protection  against  disease.  But  it  should  be  remembered  that 
half  of  all  the  patients,  the  oligophrenics,  cannot  marry  because  of 
their  disease;  and  the  same  is  true  of  those  schizophrenics  who  are 
afflicted  w^hen  young.  Other  abnormal  individuals  do  not  marry  be- 
cause of  various  psychic  reasons,  and  people  who  are  divorced  are 
ver>^  often  not  normal.  Thus  there  remain  only  the  widows  and 
widowers  that  could  demonstrate  the  danger  of  being  single  and  it 
is  really  said  that  the  latter  become  sick  more  frequently  than  the 
married. 

According  to  experience  civilization,  so  called,  is  one  of  the  most 
important  breeding  places  of  mental  diseases.  The  "higher"  the 
scale  of  civilization  the  more  insane  are  noted.  Of  course,  this  is 
in  part  misleading  because  the  care  of  the  helpless  that  civilization 
demands  simply  does  not  permit  them  to  perish  as  they  do  under 
natural  conditions.  Nevertheless  there  is  no  doubt  that  our  kind 
of  civilization  does  favor  the  disease  causing  agencies,  of  alcohol 
and  lues,  and  in  America  it  was  discovered  that  the  negroes,  who  as 
slaves  had  no  percentage  of  insanity  worth  mentioning,  become  insane 
in  greater  numbers  the  more  they  approach  the  manner  of  living 
of  the  whites,  and  that  in  the  northern  states  where  thej^  are  quite 
acclimated  they  also  attain  the  same  morbidity.  Furthermore,  it 
cannot  very  well  be  otherwise  than  that  the  elimination  of  natural 
selection  gradually  increases  the  number  of  abnormals.  As  far  as 
the  neuroses  and  obvious  psychopathies  are  concerned,  it  goes  with- 
out saying,  that  under  complicated  living  conditions,  where  a  con- 
science and  feeling  of  responsibility  exist  and  are  continually  needed, 
they  must  more  frequently — let  us  say  come  to  light  than  in  carefree 
and  unconcerned  people.  That  those  who  lead  the  parvenu  life  of 
a  metropolis  commit  race  suicide  in  doing  so,  has  been  known  for 
a  long  time,  but  the  path  from  the  normal  to  extinction  probably 
traverses  in  part  mental  degeneration.  Furthermore,  just  as  in  domesti- 
cation of  animals  the  artificial  construction  of  human  relationships 
will  produce  all  sorts  of  deviations  from  the  normal.  Though  difii- 
cult  to  evaluate,  it  is  an  important  circumstance  that  education  is 
now  fraught  with  infinitely  more  dangers  than  in  primitive  times 


CAUSES  OF  MENTAL  DISEASES  2(J9 

when  the  little  ones  did  not  soil  the  curtains  and  could  not  break  the 
statuary. 

Naturally  this  is  not  the  place  to  go  into  the  details  of  the  com- 
plicated conditions  of  the  artificial  deterioration  of  race  hygiene  in 
a  big  city;  it  is  sufficient  to  know  that  insanity  increases  with  the 
density  of  population. 

Great  significance  has  always  been  ascribed  to  sexual  conditions, 
and  it  is  not  to  be  denied  that  at  times  a  case  of  gonorrha-a  in  a 
college  boy  who  still  has  a  sense  of  decency  may  release  a  depression 
that  must  be  designated  as  morbid.  Diseases  of  the  feminine  genitals 
are  still  more  frequently  blamed  and  for  that  reason  operated  upon — 
but  without  valid  proof.  The  most  severe  blame  is  attached  to  onanism, 
which  is  supposed  to  cause  all  neuroses  and  some  of  the  more  serious 
mental  diseases,  and  the  patients  themselves  like  to  support  this 
view.  But  we  see  that  it  is  carried  on  to  an  incredible  high  degree 
by  care-free  insane  patients  and  moral  defectives  without  visible 
harm'.  Direct  bodily  injury  can  hardly  be  proven  unless  one  wishes 
to  regard  here  the  more  or  less  painful  feeling  of  weakness  in  the 
back  that  suggests  similar  menstrual  complaints  and  not  seldom  seems 
to  follow  excesses.  The  real  conditions  are  about  as  follows:  Onanism 
is  an  unnatural  gratification  of  the  most  important  instinctive  impulse 
of  mankind  which  can  be  carried  on  very  easily  and  consequently 
leads  not  only  to  over-indulgence  but  would  endanger  the  existence 
of  the  race  if  there  were  no  inhibitions  against  it.  It  is  there- 
fore comprehensible  that  our  instincts  are  so  ordered  that  our  feeling 
revolts  against  it.  This  feeling  is  supported  by  social  and  re- 
ligious command  and,  perhaps,  most  strongly,  even  though  in  a  harm- 
ful way,  by  a  literature  that  pictures  for  the  adolescent  in  the  most 
horrible  colors  the  consequences  of  the  evil,  in  order  to  extort  money 
from  him  for  cures.  Thus  where  anxiety  states  and  ideas  of  sin 
appear,  we  usually  also  find  accentuated  ideas  of  self-accusations 
concerning  onanism  which  is  thought  at  least,  even  if  not  always 
expressed.  Onanism  then  becomes  the  unpardonable  sin,  and  we  see, 
moreover,  that  the  fear  of  having  harmed  oneself  becomes  the  cause 
of  many  neurotic  conditions,  which  can  improve  as  soon  as  this  fear 
is  removed."  Naturally  the  useless  struggle  against  the  bad  habit 
and  the  resulting  loss  of  self-respect  result  in  very  harmful  factors. 
However,  onanism  is  often  a  symptom  of  disease,  especially  when 
it  is  overdone  or  carried  on  in  early  childhood;  or  as  a  result  of 
schizophrenic   shamelessness  it  becomes  apparent  not  only   because 

^Bleuler:  Der  Sexualwiderstand.  Jahrbueh  f.  Psvchoanalyt.  Forschungen  BA 
V,  1913. 


210  TEXTBOOK  OF  PSYCHIATRY 

it  is  more  frequent  but  also  because  it  is  practiced  without  fear  before 
others. 

With  a  certain  emphasis  some  nowadays  also  include  sexual 
abstinence  among  the  causes  of  neuroses  and  even  of  mental  diseases 
— but  again  without  any  proof.  The  daughters  of  certain  classes, 
catholic  priests,  as  well  as  other  chaste  people,  really  offer  sufficient 
refutation;  but  it  must  be  admitted  that  the  general  attitude  has 
become  so  frivolous  that  in  many  places,  at  least  among  the  males, 
almost  only  psychopaths  remain  chaste.  If  then  many  of  these  be- 
come sick,  it  is  surely  wrong  to  blame  their  continence. 

Among  the  sexual  functions  menstruation  has  a  certain  causal  sig- 
nificance for  the  psychoses.  It  rarely  happens  that  the  beginning 
of  maturity  is  marked  by  conditions  similar  to  twilight  or  schizo- 
phrenic states,  which  recur  a  few  times  at  intervals  corresponding 
to  the  menstrual  period  but  disappear  with  the  regular  setting  in  of 
the  menses,  without  leaving  any  psychopathic  traces.  Later  the 
menstrual  moodiness  which  is  not  uncommon  in  "normal  women"  might 
be  heightened  to  a  degree  that  may  be  designated  as  melancholic 
depression;  at  all  events  suicides  among  women  occur  noticeably 
often  at  this  time.  States  of  confusion  also  are  said  to  occur  with 
or  without  impulsive  acts.  In  addition  the  menstrual  period  can  set 
free  fairly  regular  attacks  of  manic  depressive  insanity,  while  existing 
psychoses  are  very  often  temporarily  exacerbated  at  this  time.  But 
it  is  a  plain  confusion  of  cause  and  effect,  if  the  cessation  of  the 
flow,  so  common  at  the  beginning  of  an  acute  psychosis,  is  repre- 
sented as  the  cause  of  the  insanity.  A  "menstrual  insanity"  in  any 
definite  sense  has  not  been  demonstrated  in  spite  of  different  attempts. 

The  name  puerperal  (psychoses,  those  psychoses  that  appear  during 
delivery  and  up  to  about  four  or  six  weeks  after  it,  are  contrasted  on 
the  one  hand  with  pregnancy  and  lactation  psychoses,  and  on  the 
other  hand  the  term  is  used  to  designate  all  of  the  three  forms.  But 
there  are  no  special  puerperal  psychoses  either  in  the  wider  or  nar- 
rower sense  of  the  term.  Nevertheless  pregnancy  in  psychopathic 
women,  aside  from  the  most  different  neurotic  symptoms,  may 
obviously  also  condition  melancholic  depressions  in  both  psychic  and 
somatic  ways,  or  in  both  together.  The  delusions  of  such  a  psychosis 
usually  refer  to  the  pregnancy  and  future  of  the  child  and  disappear 
after  delivery  without  leaving  any  traces.  It  rarely  causes  the  ex- 
acerbation of  a  schizophrenia,  otherwise  it  is  probably  a  case  of 
chance  coincidence  of  pregnancy  and  insanity.  Cases  of  amentia 
resulting  from  exhaustion,  hemorrhage,  or  infection  are  said  to  appear 
in  child  bed.    According  to  my  experience  it  is  nearly  always  a  case 


CAUSES  OF  MENTAL  DISEASES  211 

of  schizophrenia  which  becomes  manifest  or  a  schizophrenic  exacerba- 
tion, the  release  of  which  is  to  be  explained  mostly  along  psychic 
lines.  Even  a  manic  depressive  attack  may  sometimes  be  precipi- 
tated by  parturition.  The  lactation  psychoses  have  little  practical 
significance. 

At  the  time  of  the  female  climacterium  a  slight  accumulation  of 
exacerbations  of  different  psychoses  shows  itself;  it  also  brings  with 
it  a  particular  tendency  to  depressions.  About  a  decade  later  we  also 
see  in  men  mild  but  long  lasting  curable  depressions  that  belong  to 
the  period  of  involution  (climacterium  virile).  Real  climacteric 
psychoses  in  women,  which  formerly  were  not  uncommon,  have  dis- 
appeared from  the  literature  of  the  last  few  years. 

For  the  remainder,  the  sexual  life  has  much  to  do  with  the  causa- 
tion of  mental  diseases,  especially  of  the  psychoneuroses  by  way 
of  psychic  influences;  but  we  are  far  from  being  clear  concerning 
the  degree  and  kind  of  its  effects.^^ 

Among  the  other  psychic  causes  an  unsuitable  education  is  cer- 
tainly to  be  mentioned;  as  a  matter  of  fact  it  is  always  being  dis- 
cussed although  to  be  sure  very  little  is  known  about  it.  We  have 
good  reasons,  however,  for  the  assumption  that  many  neuroses  originate 
through  the  aid  of  poor  educational  influences. 

In  later  life  it  is  only  affective  influences  stirring  the  mind  deeply 
or  for  a  long  time  that  enter  into  consideration  as  causes  of  neuroses 
and  psychoses.  To  what  extent  care  and  sorrow  produce  real  psycho- 
ses is  not  yet  known;  no  doubt  the  importance  of  their  role  is 
exaggerated  by  the  layman,  whereas  dissatisfaction,  the  feeling  that 
life  has  been  a  failure  and,  above  all,  erotic  difficulties  (in  the  wider 
sense)  causes  flare-ups  of  neuroses  and  exacerbations  of  the  psychoses. 
In  psychopathic  persons  terror,  anger,  or  despair  can  produce  excite- 
ments of  blind  rage  with  subsequent  amnesia  or  stuporous  states 
(emotional  psychoses,  anxiety  deliria) ,  which  quickly  pass  away. 
Imprisonment  precipitates  different  psychopathic  conditions,  also  such 
resembling  paranoia;  it  is  also  said  that  operations  produce  mental 
diseases.    This  is  undoubtedly  very  rare. 

Modern  accident  laius  arouse  imaginative  desires  and  have  con- 
sequently become  the  most  important  causes  of  traumatic  neuroses 
in  the  wider  sense.  Other  transient  mental  and  nervous  disturbances 
originate  in  great  catastrophes,  as  in  earthquakes.^^ 

The  public  often  fears  infection  from  the  insane.     It  does  not 

"Concerning  the  Freudian  viewpoint  Cf.  some  observations  in  the  chapter 
on  neuroses. 

"  Cf .  Fright  neuroses. 


212  TEXTBOOK  OF  PSYCHIATRY 

exist  in  this  form.  On  the  other  hand  energetic  patients  can  impart 
their  mania  to  the  apparently  healthy  who  live  with  them  {induced 
insanity).  To  be  sure,  occasionally  even  the  entirely  healthy  are 
dragged  along  by  insane  litigants  or  reformers.  Thus  from  induced 
insanity  there  are  all  the  intermediate  stages  to  psychic  and  nervous 
epidemics,  such  as  chorea  major,  tic  epidemics  in  schools,  and  re- 
ligious epidemics,  that  certainly'  may  attack  even  well  balanced 
natures. 

Childhood  disposes  to  brain  diseases,  and  above  all  to  polioen- 
cephalitis. "Child  (psychoses"  sui  generis  are  not  known,  unless  one 
so  designates  oligophrenias  which  are  to  be  attributed  to  diseases  of 
infancy,  paresis  which  comes  from  hereditary  syphilis,  and  the  epilepsies 
that  break  out  at  this  age.  Schizophrenia  also,  and  more  rarely 
manic  depressive  insanity,  at  times  begin  in  early  childhood.  Deliria 
in  childhood  are  comparatively  frequent  in  cases  of  intoxication 
and  infection;  occasionally  they  show  at  these  times  catatonic  symp- 
toms, (e.g.  catalepsy),  which  have  no  deleterious  significance  under 
these  circumstances.  Hysterias  in  childhood  are  frequently  mono- 
symptomatic  and  have  less  the  character  of  a  psychic  general  disease 
than  those  of  adults. 

The  disposition  to  mental  disease  increases  explosively  with 
puberty;  and  where  neither  alcoholism  nor  paresis  constitutes  an 
essential  part  of  the  disease,  the  disposition  decreases  slowly  from 
the  twenty-fifth  year  and  quickly  between  thirty-five  and  forty. 

A  "puberty  psychosis"  peculiar  to  the  period  of  development  is  not 
yet  known,  unless  the  above  mentioned  coincidences  previous  to  the 
inception  of  menstruation  are  to  be  called  so.  What  used  to  be  so 
designated  were  usually  schizophrenias. 

During  manhood  the  alcoholics,  paretics  and  paranoiacs  become 
manifest,  then,  also  the  traumatic  cases  from  comprehensible  external 
causes. 

The  period  of  involution  brings  with  it  a  small  increase  of  schizo- 
phrenic conditions,  a  more  considerable  increase  of  depressions,  and 
then  a  number  of  less  common  diseases,  some  of  which  were  described 
by  Kraepelin.  But  the  period  of  involution  is  to  be  sharply  differ- 
entiated in  this  respect,  as  well  as  in  general,  from  senile  degenera- 
tion, even  if  the  two  processes  may  touch  each  other.  Like  puberty, 
it  is  a  re-formation  for  another  stage  of  life;  the  normal  matron  for 
more  than  two  decades  is  still  a  capable  person. 

Senility,  on  the  contrary,  is  a  reiro-formation,  a  dying  out.  If 
the  retro- formation  of  the  brain  precedes  the  retro-formation  of  the 
other  organs,  it  shows  itself  clinically  in  the  pure  form  of  dementia 


CAUSES  OF  MENTAL  DISEASES  213 

senilis.    Moreover,  arteriosclerosis  and  presbyophrenia,  while  not  en- 
tirely peculiar  to  senility,  are  still  most  commonly  met  with  it. 

The  male  sex  is  disposed  more  than  the  female  to  idiocy  and 
epilepsy,  and  less  to  neuroses  and  manic  depressive  insanity.  If 
alcoholism  and  paresis  primarily  affect  men,  this  is  due  to  their 
manner  of  living;  that  they  prefer  this  manner  of  living,  is  again 
based  on  sex.  On  the  whole  more  men  are  taken  into  the  insane 
asylum;  but  their  numbers  are  generally  less  than  those  of  women,  be- 
cause the  alcoholics  are  usually  quickly  discharged  and  the  paretics 
die.  Among  the  older  insane  patients  there  are  more  women  because 
of  the  greater  longevity  of  the  sex. 


CHAPTER  XI 

THE  TREATMENT  OF  MENTAL  DISEASES 
IN  GENERAL 

The  treatment  will  here  only  be  considered  as  far  as  it  concerns 
the  requirements  of  the  practicing  physician — and  as  far  as  its  dis- 
cussion, independent  of  clinical  demonstration,  may  be  of  some  use. 
Concerning  the  neuroses  reference  must  be  made  to  textbooks  on 
neurology} 

As  yet  very  little  is  done  for  prophylaxis,  and  without  a  change 
of  the  general  attitude  and  legislation  very  little  can  be  done.  The 
more  severely  burdened  should  not  propagate  themselves.  Some 
have  recommended  "social  sterilization";  others  have  challenged  ''the 
infringement  upon  human  rights"  and  found  it  useless.  Many  dis- 
eased and  degenerates  are  themselves  quite  willing  to  undergo  the 
operation,  and  though  the  opportunity  may  not  be  very  frequent, 
it  may  be  of  use  in  individual  cases.  Moreover  the  idea  is  capable 
of  expansion,  and  that  is  just  what  is  feared.  I  do  not  fear  it:  because 
as  long  as  the  now  current  attitude  is  not  completely  changed,  the 
danger  of  overdoing  exists  almost  only  in  so  far  as  the  practice  would 
get  ahead  of  the  development  of  the  ideas  and  consequently  might 
for  a  long  time  discredit  these  measures.  I  would  begin  with  compul- 
sion in  the  case  of  incurable  criminals  and  on  the  basis  of  consent  in 
the  case  of  other  more  serious  psychopathies,  and  then  gradually  alter 
the  general  attitude  and  legislation  in  accordance  with  experience. 
But  if  we  do  nothing  but  make  mental  and  physical  cripples  capable 
of  propagating  themselves,  and  the  healthy  stocks  have  to  limit 
the  number  of  their  children  because  so  much  has  to  be  done  for 
the  maintenance  of  the  others,  if  natural  selection  is  generally  sup- 
pressed, then  unless  we  will  get  new  measures  our  race  must  rapidly 
deteriorate. 

Also  the  deleterious  influences  that  act  on  the  germ,  among  which 
I  class  the  living  conditions  in  large  cities,  should  be  seriously  attacked. 
To  quote  Kraepelin:  "It  must  also  be  the  sacred  duty  of  physicians 

^  Comp.  especially  the  chapter  on  Psychotherapy  by  Mohr  in  Lewandowsky, 
Handbuch  der  Neurologie,  Julius  Springer,  Berlin.  And  Schultz,  Die  Seelische 
Krankenbehandlung  (Psychotherapie).    Fischer,  Jena  1920. 

214 


THE  TREATMENT  OF  MENTAL  DISEASES  IX  GENERAL  215 

to  increase  gradually  the  pressure  of  public  opinion  in  such  a  way 
that  the  resolution  will  be  formed  to  take  up  the  battle  against  alcohol 
and  syphilis  with  the  same  emphasis  and  the  same  resort  to  remedies 
as  in  the  battle  against  tuberculosis."  All  "Back  to  nature"  move- 
ments also  are  to  be  supported  much  more  energetically  than  here- 
tofore, but  not  to  the  bogey  that  is  called  nature.  Even  in  our  in- 
dustrial age  the  race  sustaining  power  of  agriculture  could  be  utilized 
for  prophylactic  measures. 

A  purposeful  bringing  up  might  perhaps  prevent  many  a  neurosis. 
We  see,  at  least,  nervousness  and  morbid  characteristics  grow  directly 
from  an  inadequate  training  and  must  therefore  conclude  that  proper 
influences  with  training  of  the  will  and  particularly  of  the  character 
to  become  habituated  to  tolerate  the  disagreeable,  including  pain,  and 
hardened  within  sensible  limits — all  that  could  preserve  from  sickness 
many  who  are  not  too  severely  burdened.  A  careful  selection  of 
vocation  will  also  furnish  a  certain  protection.  It  is  also  conceivable 
that  the  timely  solution  of  inner  conflicts  in  the  milder  schizophrenic 
process  could  postpone  the  breaking  out  of  secondary  symptoms,  i.e. 
of  the  manifest  insanity. 

In  pronounced  disease  the  chronic  cases  should  be  differentiated 
from  the  acute.  The  chronic  cases,  for  the  great  part,  are  to  be 
trained  to  normal  conduct  and  work;  but  since  besides  physicians 
few  people  understand  such  a  training,  its  direction  is  still  the  task 
for  medical  men.  The  layman,  even  when  he  is  ever  so  well  mean- 
ing and  intelligent,  still  forgets  too  easily  the  difference  between  sick 
and  well,  and  thinks  he  can  work  with  logic  and  indignation  and 
kindliness,  as  is  properly  the  case  with  the  healthy.  But  just  in  those 
things  that  matter,  the  sick  frequently  have  a  false  logic  and  still 
less  do  they  understand  indignation  at  their  acts,  which  they  con- 
sider proper.  Or  can  gratitude  be  expected  when  they  do  not  at  all 
value  our  sacrifice  or  only  negatively,  i.e.,  when  they  take  them  as 
chicaneries?  Here  it  is  a  question  of  carefully  ascertaining  the 
patient's  general  modes  of  reaction  and  especially  those  toward  par- 
ticular individuals,  and  then  act  as  seems  best  in  the  particular  situa- 
tion, and  not  from  a  sense  of  justice,  or  anger,  or  sentimental  sympathy. 

An  indispensable  means  of  training  is  icork,  which  also  renders 
incalcuable  services  against  many  symptoms.  Whoever  considers  him- 
self too  good  for  this  or  whatever  kind  of  work  he  could  still  accom- 
plish is  not  good  enough  for  it.  But  also  in  the  beginning  of  mental 
diseases,  especially  of  schizophrenias,  one  should  not  permit  work  to 
be  dropped  at  once  without  some  definite  reason.  When  adapted  to 
the  ability  of  the  patient,  it  usually  does  more  good  than  so-called 


216  TEXTBOOK  OF  PSYCHIATRY 

rest  and  recuperation,  and  this  is  particularly  the  case  in  many  light 
melancholias  such  as  the  physician  will  most  probably  have  to  treat  in 
his  private  practice.  Mental  work,  also,  is  not  to  be  excluded  on 
principle,  even  though  it  is  frequently  not  applicable,  more  because 
of  practical  than  inner  reasons.  But  the  worst  is  "the  poison  of 
laziness"  (Rieger). 

Milder  chronic  cases  can  be  sent  with  very  good  results  to  a 
Psychiatric  clinic  where  the  patient  is  braced  up  from  time  to  time^ 
where  he  receives  the  necessary  remedies,  and  where  a  special  effort 
is  made  to  make  the  external  conditions  bearable. 

In  acute  diseases  the  object  of  obtaining  a  cure  is  of  uppermost 
consideration,  but  unfortunately  we  cannot  do  as  much  as  we  should 
like.  In  individual  cases  special  psychiatry  has  to  lay  down  the 
necessary  rules. 

An  important  question  is  "Which  patients  are  to  be  committed  to  a 
hospital  for  the  insane?"  Naturally,  all  those  who  cannot  be  kept  out- 
side because  they  are  too  dangerous  to  themselves,  to  others,  or  too 
disturbing.  Some  can  be  properly  treated  only  in  an  institution  be- 
cause they  themselves  or  sometimes  their  relatives  oppose  a  proper 
management  of  the  case.  Where  the  danger  to  the  patient's  fortune  is 
the  chief  indication,  a  legal  guardianship  can  at  times  take  the  place  of 
an  institution  or  shorten  the  stay.  Not  seldom  patients  must  be  in- 
terned, not  because  their  conditions  directly  require  itj  but  because 
their  relatives  are  worn  out  by  taking  care  of  them.  It  is  also 
not  unusual  that  the  family  exerts  a  directly  harmful  influence  on 
the  patient,  hence  the  indication  for  institutional  care  lies  in  the 
existing  conditions. 

To  intern  an  insane  patient  compliance  with  a  number  of  formalities 
is  necessary,  which  unfortunately  vary  in  different  states.  Every 
physician  who  settles  down  to  practice  should  injorm  himself  about 
these  local  formalities;  if  he  waits  until  the  occasion  arises  he  is 
apt  to  encounter  many  difficulties.  In  almost  every  state  a  physician's 
certificate  is  required.  In  the  state  of  New  York  it  is  a  legal  act  and 
must  therefore  be  carefully  filled  out  with  the  required  data.  Be- 
sides the  petition  to  the  court,  signed  if  possible  by  the  nearest  rela- 
tive, it  must  also  contain  a  physician's  certificate  signed  by  two 
qualified  examiners  in  lunacy  who  must  examine  the  patient  conjointly 
within  five  days  of  the  presentation  of  the  petition.  Such  a  certificate 
must  contain  information  about  the  patient's  legal  standing  whether 
he  is  charged  with  a  criminal  act  or  not,  his  financial  standing 
whether  he  has  relatives  who  are  able  to  pay  for  his  maintenance  in 
the   hospital    (if  not  committed  to   a   private   institution)    and  the 


THE  TREATMENT  OF  MENTAL  DISEASES  IN  GENERAL  217 

physical  and  mental  states  of  the  patient,  whether  he  is  dangerous 
to  himself  and  others,  whether  he  shows  hallucinations,  delusions, 
depression,  exaltation  or  other  abnormal  signs.  It  is  often  not  possible 
to  make  a  definite  diagnosis  after  one  examination  but  for  pur- 
poses of  commitment  this  is  not  essential.  It  is  merely  a  question 
whether  the  patient  is  insane  and  unmanageable  at  home.  The  neces- 
sity for  institutional  care  must  in  every  case  be  specified.  (Is  the 
patient  dangerous  to  the  community,  does  he  refuse  nourishment,  has 
he  suicidal  tendencies,  etc.?) 

Without  the  legal  commitment  no  insane  patient  will  be  admitted 
to  a  state  institution,  so  that  it  is  advisable  to  inquire  first  of  the 
hospital  superintendent  whether  the  patient  can  be  received.  Not  all 
hospitals  are  in  position  to  receive  patients  at  all  times.^ 

So  much  for  the  administrative  details.  In  addition  the  physician 
at  the  institution  should  receive  all  the  data  required  for  the  treat- 
ment of  the  patient,  his  outward  behavior,  presence  or  absence  of 
particular  inclinations  or  impulses,  so  that  a  harmless  patient  does 
not  have  to  be  sent  at  once  to  the  observation  ward.  He  should 
also  obtain  the  anamnesis,  information  concerning  the  patient's  past 
treatment  and  its  success;  whether  the  patient  was  given  narcotics 
on  the  trip  to  the  hospital,  which  kind,  and  in  what  doses?  Hyoscine 
can  give  the  appearance  of  a  pupillary  disturbance  and  lead  to  a 
wrong  diagnosis.  It  is  best  not  to  give  narcotics  on  the  first  day  if 
one  does  not  know  whether  the  patient  has  already  been  given  the 
same.  Sometimes  the  physician  has  no  time  to  ascertain  all  this  and 
make  a  note  of  it.  Then  he  sends  with  the  patient  a  preliminar}- 
certificate  with  the  necessary  data  and  states  that  the  detailed  re- 
port will  be  sent  on  the  following  day. 

Moreover  the  hospital  physician  will  be  grateful  to  get  not  only 
the  practically  necessary  information  but  also  that  which  may  be  sci- 
entifically interesting. 

In  bringing  a  patient  to  an  institution  one  should  not  resort  to  lies 
and  false  pretenses;  that  would  make  a  beneficial  treatment  impossible 
and  especially  in  the  case  of  patients  who  have  some  self-respect,  it 
would  permanently  disturb  the  entire  relationship  with  their  rela- 
tives. In  an  emergency  it  is  better  to  use  force  or  a  hypnotic,  which 
is  more  readily  forgiven  by  the  patient.  But  force  is  ver^*  rarely 
necessary  when  the  proper  procedure  has  been  followed.  A  large 
part  of  the  patients  can  be  persuaded,  if,  without  losing  one's  own 

'  This  is  not  necessary  in  most  of  our  big  cities  where  psychopathic  hospitals 
or  pavilions  are  maintained  for  obsei-vation,  treatment  and  commitment  when 
necessary. 


218  TEXTBOOK  OF  PSYCHIATRY 

self-possession,  one  explains  the  decision  for  a  hospital  on  grounds  of 
necessity;  but  it  must  be  told  so  decisively  that  they  feel  that  any 
discussion  whatsoever  is  useless,  and  that  there  are  enough  people 
present  who  would  be  capable  of  putting  the  thing  in  operation  in  the 
face  of  resistance.  It  should  not  be  forgotten  that  it  is  only  in  the 
rarest  case  that  logic  itself  makes  the  patient  yield;  it  is  the  personality 
of  the  individual  who  applies  the  logic. 

When  the  patient  is  in  a  hospital,  the  family  physician  fre- 
quently has  to  continue  his  function  as  advisor  of  the  family.  The 
questions  about  private  or  public  institutions,  about  visiting  the  patient 
and  taking  him  home  must  all  be  advised  by  him.  In  this  matter 
it  is  difficult  to  give  general  rules.  One  must  guard  against  giving 
advice  without  knowing  exactly  the  actual  state  of  the  case.  It 
is  best  to  get  in  touch  with  the  hospital  physician;  moreover,  in  such 
cases  professional  courtesy  is  of  greater  value  to  the  patient  and. his 
family  than  to  the  professional  relationship.  At  all  events  the  physi- 
cian should  know  that  manic  depressive  patients  are  frequently  taken 
out  too  soon,  and  schizophrenics  very  rarely,  unless  other  considerations 
than  the  patient's  condition  come  into  account.  Only  in  exceptional 
cases  is  home-sickness  an  indication  for  taking  the  patient  home; 
usually  what  the  patient  and  relatives  take  as  such  is  not  home-sick- 
ness at  all.  The  patient  does  not  feel  at  ease  anywhere  and  then 
the  cause  is  sought  in  the  separation  from  home.  Patients  who  are 
cured  hardly  ever  urge  to  be  sent  home.  The  dreaded  "living  with 
other  markedly  insane  patients"  is  sometimes  an  unpleasant  experi- 
ence but  it  is  not  a  hindrance  to  the  cure.  It  is  very  harmful  if 
visiting  relatives  give  the  patient  hopes  of  coming  home  or  of  any- 
thing else  that  cannot  be  fulfilled  later.  Moreover,  visits  are  some- 
times harmful;  they  frequently  disturb  an  acute  patient,  especially 
in  the  beginning  when  he  has  to  get  used,  to  the  institution,  I  should 
like  to  call  attention  to  the  younger  children  who  almost  without 
exception  overcome  home-sickness  after  a  few  days,  but  on  condition 
that  they  are  not  visited.  But  even  in  the  case  of  chronic  patients 
visits  interfere  with  the  adjustment  to  the  new  home  even  where  they 
are  carefully  and  tactfully  carried  out. 

The  selection  of  an  institution  is  frequentty  not  easy.  Where 
overcrowding  has  not  become  excessive,  public  institutions  are  gen- 
erally the  ones  that  accomplish  most  for  the  least  money.  This  is 
naturally  counterbalanced  by  the  fact  that  there  is  frequently  less 
comfort  and  less  consideration  for  the  wishes  and  moods  of  the  in- 
dividual. The  latter  may  also  he  an  advantage.  All  private  sana- 
toria are  far  from  being  well  equipped  for  restless  patients.    Sometimes 


THE  TREATMENT  OF  MENTAL  DISEASES  IN  GENERAL  219 

because  of  the  "odium,"  or  from  false  pride  relatives  want  to  avoid 
public  institutions  and  sacrifice  money  to  this  idea  that  would  be 
better  applied  in  other  ways,  e.g.  during  the  period  of  recuperation.^ 
But  it  is  self-evident  that  good  private  institutions  can  offer  much, 
especially  to  spoiled  patients,  that  they  are  deprived  of  in  a  public 
institution.  But  it  is  more  difficult  to  carry  out  a  rigid  training  there 
than  under  the  inexorable  rules  of  a  general  institution  (care  should 
be  taken  especially  in  deprivation  cures,  see  morphinism). 

Some  patients,  e.g.  oligophrenics  and  cases  of  schizophrenia  that 
have  run  their  course,  can  often  be  trained  with  success  or  also 
kept  for  a  long  time  in  a  private  family,  with  a  doctor,  teacher,  or 
minister.  In  some  places  private  family  care  is  publicly  organized 
also  for  the  poorer  classes  and  has  proved  to  be  very  successful.  The 
guardians  are  preferably  farmers  or  former  nurses  and  attendants 
from  hospitals. 

The  disease  itself  can  only  be  attacked  directly  in  a  few  cases  such 
as  cerebral  lues  and  epilepsy.  On  the  basis  of  chance  experience  with 
dementia  prsecox,  an  artificial  fever  has  been  produced  by  the  injec- 
tion of  bacterial  toxins  {Wagner  von  Jauregg).  The  toxins,  how- 
ever, can  be  advantageously  replaced  by  somnifen.  Tertian  plasmodia 
seem  to  neutralize  the  spirochites  in  paresis. 

In  despair  the  family  often  assumes  expensive  treatments  in  cases 
of  incurable  patients  that  set  the  family  back  financially  and  thereby 
make  a  later  proper  treatment  of  the  patients  impossible.  This  is  a 
grave  wrong.  It  should  not  be  forgotten  that  curable  cases  are 
usually  cured  for  the  m.ost  part  by  time. 

Against  emotional  fluctuations,  distraction  sometimes  has  an  effect 
only  in  milder  cases.  To  argue  with  the  patient  about  his  delusions 
is  nearly  always  useless  or  harmful.  One  should  not  conceal  his 
own  viewpoint  from  the  patient  but  at  the  most, — it  should  be  left  to 
the  future  to  prove  who  is  right. 

With  the  exception  of  the  psychoneuroses,  mental  diseases  offer 

'Such  an  odium  is  especially  entertained  in  reference  to  our  State  Hospitals, 
thus  furnishing  no  little  problem  for  the  consulting  psychiatrist.  It  is  easy 
enough  to  dispose  of  the  wealthy  patients,  thej'  are  invariably  sent  to  private 
sanatoriums,  and  of  the  greater  part  of  the  poor,  who  go  to  state  institutions, 
but  one  is  often  at  his  wits'  end  to  know  what  to  do  with  middle  class  patients 
who  cannot  afford  a  first  class  sanatorium  and  would  under  no  circumstances 
go  to  a  State  Hospital.  I  have  known  families  who  actualh-  became  ruined 
financially  in  their  zeal  of  maintaining  a  praecox  in  a  third  rate  private  sana- 
torium. The  State  Hospital  could  have  offered  them  just  as  good, — in  my 
opinion  much  better — service,  but  owing  to  the  mediaeval  prejudices  which  our 
newspapers  continually  change  into  modern  garb,  the  average  person  is  still 
horrified  when  a  public  institution  is  suggested.     (Editor.) 


220  TEXTBOOK  OF  PSYCHIATRY 

no  fertile  field  for  psychotherapy  in  the  narrower  sense.*  Manic 
depressives,  and  similar  cases  recover  from  the  attack,  organic  cases 
perish,  while  schizophrenics  live  on  uncured.  But  just  in  the  case 
of  the  latter  it  is  of  especial  importance,  whether  one  understands 
them,  and  can  think  oneself  into  their  condition,  only  an  extensive 
occupation  with  psychopatholog^-,  delusional  and  symptomatic  forma- 
tions, blockings  and  inhibitions,  can  assist  in  this.  Suggestion,  whether 
direct  or  concealed,  will  always  be  carried  on,  just  as  in  medical 
practice  and  in  life  generally.  In  some  cases  hypnosis  may  make  many 
things  easier,  e.g.  in  residual  conditions  like  insomnia  following  mel- 
ancholia. On  the  whole,  its  significance  in  real  psychoses  ^  is  not  great, 
because  as  Forel  expressed  it,  in  hypnosis  one  works  with  the  patient's 
brain,  which  in  the  case  of  mental  diseases  is  an  ineflBcient  instrument. 
One  of  the  most  important  psychical  means  of  therapy  is  patience, 
calm,  and  inner  good  will  for  the  patient,  three  things  that  must  be 
absolutely  inexhaustible. 

From  definite  "procedures"  in  the  case  of  psychoses  in  the  narrower 
sense,  very  little  is  to  be  expected  even  though  milder  cases  at  times 
are  favorably  influenced  in  hydrotherapeutic  institutions  where  one 
exercises  care.  A  careless  application  of  cold  water  may  do  decided 
harm.  On  the  other  hand  baths  of  normal  or  near  normal  bodily 
temperature  are  an  important  help  in  the  treatment  of  restless  and 
sometimes  also  of  depressed  patients.  Excitements  are  often  reduced 
by  a  bath ;  a  feeling  of  tiredness  without  a  real  reduction  of  psychical 
and  physical  capacities  makes  the  patient  more  accessible.  But  even 
in  those  cases  where  this  result  is  not  visible  the  tepid  bath  (35  to 
36°  C.)  is  an  excellent  resort  for  the  patients  who  can  constantly 
occupy  themselves  with  the  water  and  thus  remain  harmless  to  them- 
selves, to  others  and  to  the  objects  about  them.  The  introduction 
of  the  continuous  baths,  used  also  in  some  institutions  throughout 
the  night,  and  the  use  of  wards  for  sleepless  patients,  has  given  the 
modern  insane  asylum  a  much  better  appearance.  The  depressed 
patients  also  are  frequentty  better  off  in  the  bath;  a  warm  bath, 
taken   at  night,  is  especially   conducive  to   sleep. 

Cold  packs  are  also  frequently  applied,  and  the  patient  is  kept 
in  them  for  about  twenty  minutes  until  he  gets  warm  or  even  for 
many  hours.    The  latter  is  only  resorted  to  in  the  case  of  good  con- 

*  That  is,  psychotherap}^  according  to  definite  methods,  such  as  that  of  Freud, 
Dubois,  hypnotism,  etc.  It  is  self-evident  that  "psychotherapy"  in  a  wider 
sense  is  practiced  by  ever>'  psychiatrist, — I  should  almost  like  to  saj^  not  as  such. 

"  In  contradistinction  with  the  neuroses.  Even  those  who  are  not  very  skilled 
in  hypnosis  will  find  that  such  cases  as  monosymptomatic  hysteria  or  enuresis 
are  frequently  readily  susceptible  of  this  treatment. 


THE  TREATMENT  OF  MENTAL  DISEASES  IN  GENERAL  221 

trol  of  temperature,  appearance,  and  psychical  condition.  Occasionally 
they  also  have  a  soothing  effect.  But  if  the  arms  are  not  wrapped 
up,  they  are  not  tolerated  for  long,  ju^t  by  those  patients;  who  need 
packs  most;  and  if  they  are  put  under  the  blanket  this  procedure,  ac- 
cording to  my  way  of  thinking  and  that  of  my  patients,  becomes,  under 
the  guise  of  medicine,  the  worst  means  of  restraint  that  exists.  I 
therefore  avoid  packs  as  much  as  possible. 

Very  many  patients,  especially  the  depressed,  also  schizophrenics 
who  do  not  occupy  themselves,  and  mild  manics  are  best  off  in  bed; 
if  they  want  to  occupy  themselves,  there  is  no  objection  to  reading, 
writing,  and  feminine  handwork.  Every  modern  institution  has  a 
number  of  wards  where  the  patients  remain  in  bed  day  and  night  under 
constant  surveillance,  but  there  must  be  a  definite  indication  for 
this;  one  should  not  merely  feel  that  "patients  should  be  in  bed." 
In  chronic  cases  work  is  to  be  preferred  if  it  is  possible. 

If  patients  are  very  excited  or  annoy  and  injure  others,  they  are 
under  eertain  circumstances  isolated.  Nowadays  there  are  physicians, 
and  there  were  even  more  ten  or  twenty  years  ago,  who  regard  isola- 
tion as  an  atrocity.  With  discrimination,  properly  applied,  I  consider 
it  a  blessing  for  all  concerned.  In  the  case  of  manics  who  do  not 
necessarily  soil  everything  it  is  the  preferred  therapy.  And  at  night 
probably  every  healthy  person  would  prefer  to  be  alone  in  a  room, 
even  if  it  is  called  a  cell,  rather  than  in  the  company  of  many  lunatics. 

Other  means  of  restraint  are  to  be  applied  most  rarely;  but  when 
there  is  a  special  indication,  as  in  the  treatment  of  a  fracture,  I  con- 
sider it  wrong  to  let  the  patient  become  a  cripple  because  of  considera- 
tion of  principle. 

Where  artificial  feeding  is  necessary,  the  patient  can  only  rarely 
be  kept  in  a  private  house.  A  well  nourished  person,  if  he  remains  in 
bed,  can  go  without  food  from  five  to  seven  days  without  harmful 
effects,  unless  he  has  previously  put  himself  on  half  rations.  One 
should  not  bother  with  rectal  feeding  and  similar  emergency  measures. 
On  the  other  hand  there  are  sometimes  roundabout  ways  by  which 
nourishment  may  be  given  the  patient;  thus  some  will  eat  secretly, 
if  food  is  left  within  their  reach  as  if  by  accident.  If  tube  feeding 
is  necessary,  it  is  best  done  through  the  nose.  The  patient  is  held 
in  a  reclining  or  sitting  position  firmly  enough  to  preclude  a  struggle 
during  the  process.  Then  a  well  lubricated  soft  tube  is  inserted  into 
the  wider  nostril,  so  thick  that  it  just  goes  through.  The  bending 
at  the  posterior  wall  of  the  throat  is  forced  by  a  little  push.  From 
here  on  the  insertion  should  be  made  somewhat  quickly,  so  that  the 
patient  has  not  time  to  guide  the  tube  into  the  mouth. 


222  TEXTBOOK  OF  PSYCHIATRY 

In  any  case,  it  is  often  well  to  wait  for  the  pharyngeal  reflex 
and  as  soon  as  it  begins,  to  shove  the  tube  into  the  oesophagus.  It 
is  then  inserted  into  the  stomach,  and  through  the  auscultation  of  a 
little  air,  blown  in  by  balloon  or  mouth,  one  makes  sure  of  the  cor- 
rect position  of  the  tube.  Lack  of  reaction  by  the  patient,  especially 
in  the  case  of  catatonics,  is  no  guarantee  that  the  tube  is  not  in  the 
trachea.  When  the  tube  is  withdrawn  the  tube  should  be  pinched  shut 
so  that  nothing  flows  into  the  larynx.  The  simplest  thing  to  inject 
is  milk  and  half  as  many  eggs  as  a  deciliter  of  milk.  After  a  pro- 
longed fast  one  may  pour  in  five  deciliters  at  the  most  the  first  time, 
later  one  liter  of  milk  and  five  eggs  at  a  time.  Two  daily  feedings 
will  then  usually  suffice.  The  state  of  nourishment,  digestion,  vomiting, 
are  naturally  always  to  be  watched  carefully.  Medicines  may  also 
be  mixed  with  the  food  and  in  case  of  a  longer  period  of  illness  a 
different  food,  in  fluid  or  semifluid  condition,  will  probably  be  given 
in  place  of,  or  in  addition  to,  milk. 

If  the  patient  causes  special  trouble,  he  should  be  committed  to  an 
institution.  In  case  of  narrow  nostrils  the  insertion  of  the  tube 
through  the  mouth  may  sometimes  become  necessary,  also  to  wash 
out  the  stomach  after  poisoning.  In  the  case  of  patients  who  offer 
resistance  one  must  use  a  gag  and  be  sure  to  protect  one's  fingers; 
then  insert  tenderly  but  without  fussiness  the  left  index  and  middle 
fingers  until  reaching  the  back  of  the  epiglottis  which  is  pressed  for- 
ward a  little.  Guide  the  tube  between  the  two  fingers  directly  to  the 
entrance  of  the  oesophagus,  which  can  only  be  forced  in  this  way 
by  a  soft  tube  against  the  patient's  will. 

Electricity,  massage,  climatic  influences  cannot  be  used  as  yet. 
Nor  can  hardly  anything  be  gained  by  a  definite  manner  of  nourish- 
ment; special  additional  indications  naturally  excepted  (compare  also 
therapy  of  epilepsy).  On  the  other  hand  strong  nerve  stimulants  such 
as  coffee  and  tea  should  be  avoided,  and  above  all  alcohol  has  so  many 
disadvantages  that  the  little  benefit  which  here  and  there  is  sometimes 
claimed  for  it  does  not  enter  into  consideration. 

Hypnotics  can  never  be  dispensed  with  entirely;  in  institutions 
they  must  often  be  given  because  of  the  other  patients  whom  an  ex- 
cited patient  keeps  awake.  Certainly  the  less  one  uses,  the  better; 
but  if  one  is  careful,  that  is,  if  one  never  gives  it  daily  for  any  length 
of  time  and  changes  the  drugs,  one  will  not  have  any  unpleasant  ex- 
periences. To  be  sure  one  must  watch  the  urine  for  the  effect  on 
the  blood  when  administering  Sulfonal  and  Trional.  Chloral  Hydrate 
is  still  one  of  the  best  drugs  when  given  in  doses  of  2-3  Gm.  (Blood 
pressure!)    and    eventually    in    smaller    doses    together    with    mor- 


THE  TREATMENT  OF  MENTAL  DISEASES  IN  GENERAL  223 

phine.  Of  the  newer  drugs  Veronal  (0.5  to  L5;  eare  nephritis!) 
and  Veronal  of  Soda  (0.5  to  LOj  are  particularly  useful.  The  latter 
may  also  be  given  in  enemas.  Trional  and  Sulfonal  are  also  given; 
the  former  acts  quickly  but  not  continuously,  the  latter  slowly  but 
effectively  and  very  readily  shows  a  cumulative  effect.  Hence  LO 
Trional  can  sometimes  be  combined  with  2.0  Sulfonal  to  obtain  an  im- 
mediate and,  at  the  same  time,  a  more  lasting  effect.  In  the  case 
of  excitations  of  not  too  long  duration  a  certain  calming  effect  can 
be  attained  with  Sulfonal,  if  it  is  frequently  given  (the  cumulative 
effects  manifest  themselves  by  disturbances  of  coordination).  The 
specified  doses,  with  the  exception  of  those  of  Sulfonal  and  Trional, 
may  be  exceeded  without  danger  with  patients  whose  reaction  is  known. 
In  real  excitations  energetic  doses  should  be  administered  or  none 
at  all;  one  should  be  glad  if  anything  at  all  produces  results.  Paralde- 
hyde (5.0  per  dose  and  more,  always  through  the  mouth)  would  be 
one  of  the  best  hypnotics  if  it  did  not  have  such  a  bad  taste  and  odor. 
In  single  doses  it  is  entirely  harmless,  but  it  cannot  be  given  for  a 
long  period.  Amylene  hydrate  (2.0  to  5.0)  is  well  adapted  for  rectal 
administration  and  is  sometimes  successfully  used  especially  in  status 
epilepticus;  but  it  must  be  well  diluted  with  starch  or  something  similar 
when  given  as  an  enema,  otherwise  it  attacks  the  mucous  membrane  of 
the  intestines. 

Many  recommend  alcohol  as  a  hypnotic.  It  is  the  pleasantest,  but 
as  it  may  become  a  habit  it  is  the  most  dangerous  and  least  effective. 
I  do  not  think  it  worthy  of  physicians  to  prescribe  a  drug  which  is 
most  pleasant  but  most  dangerous  and  ineffective.^ 

In  nervous  excitements  resulting  from  fatiguing  W'Ork  bromide  in 
smaller  doses  is  excellent  (1  to  3  grammes  to  be  taken  evenings  all 
at  once,  or  perhaps  still  better  in  two  doses,  but  it  must  be  thoroughly 
diluted).  In  milder  depressions  it  is  more  rarely  effective,  in  severer 
ones  not  at  all  (comp.  Melancholia). 

Opium  and  opiates  are  not  hypnotics.  But  indirectly  by  removing 
fear  and  psychic  pain  they  can  have  a  calming  or  even  hypnotic  effect. 
In  psychoses,  however,  they  do  not  achieve  by  far  what  their  effects 
on  the  healthy  would  lead  one  to  expect.  With  the  exception  of  a  few 
cases,  their  use  can  be  dispensed  with,  and  because  the  danger  of 
habituation  to  opiates  is  very  great,  especially  with  psychopaths, 
there  is  good  reason  to  avoid  them  as  much  as  possible.    To  give  opiates 

•If  it  is  supposedly  necessary  for  any  other  reason  to  prescribe  alcohol  as  a 
medicine,  it  should  be  prescribed  like  any  other  remedy  in  definite  doses  and — 
for  self-evident  reasons — without  the  patient  knowing  it,  as:  Spir.  Vin.  30.0. 
Aqua  130.0,  Syr.  Liquir.  40.0. 


224  TEXTBOOK  OF  PSYCHIATRY 

to  an  excited  patient  to  facilitate  the  transfer  to  an  institution  is 
hardly  ever  of  any  use  but  it  constantly  occurs  nevertheless. 

Hyoscine  (Scopolamin,  Euscopol)  hypodermatically  in  doses  of 
0.8  to  1  mg.  (above  the  maximum  dose!)  is  best  in  such  cases;  if  the 
patient's  reaction  is  known  and  the  drug  is  fresh,  more  may  be  given, 
up  to  1.5  mg.  It  has  a  decidedly  better  effect  in  combination  with 
morphine — ten  times  the  dose  of  hyoscine— and  in  frequent  use  this 
addition  overcomes  the  harmful  influence  of  hyoscine  on  the  digestion. 
If  one  gives  smaller  doses  of  hyoscine  (about  0.3  mg.)  as  some  recom- 
mend, one  can  add  more  morphine,  e.g.  0.015  g.  per  dose.  Within 
more  recent  times  somnijen  has  been  used  both  as  a  hypnotic  and 
sedative  (40-50  minims  internally;  some  give  bigger  doses).  The 
more  exact  medications  are  still  to  be  determined.^ 

Among  particular  symptoms  which  the  practicing  physician  has  to 
deal  with,  undeanliness  should  be  mentioned.  Many  mechanical  ar- 
rangements have  been  constructed,  particularly  for  the  unclean  bed 
cases,  and  all  have  been  given  up.  The  best  thing  is  immediate  clean- 
ing, day  and  night,  after  every  evacuation.  In  many  patients,  es- 
pecially those  not  paralyzed,  smearing  of  feces  can  be  done  away 
with,  if  every  evening,  if  possible  at  exactly  the  same  time,  they  are 
given  an  enema  and  urged  to  move  their  bowels. 

Formerly  it  was  thought  necessary  to  do  much  to  prevent  masturba- 
tion.^ This  struggle,  which  is  not  only  useless  but  which  also  keeps 
the  attention  of  the  inmates  of  the  institution  directed  to  the  evil,  I 
gave  up  long  ago  and  am  glad  of  it.  But  at  all  events  care  must 
be  taken  that  onanistic  acts  are  not  carried  on  openly  and  do  not 
anger  the  others  or  infect  them.  In  cases  where  the  patients  them- 
selves are  struggling  against  the  impulse,  medium  doses  of  bromide 
(2.0  to  4.2  per  day)  are  sometimes  effective.  Epiglandol,  which  to  be 
sure  is  better,  can  also  diminish  the  impulse. 

For  a  treatment  of  the  danger  of  suicide  see  manic-depressive 
insanity. 

If  operations  on  the  iiisane  are  to  be  undertaken,  unless  it  is  a 
question  of  life  and  death  which  makes  immediate  action  necessary, 
one  should  obtain  the  consent  of  the  relatives  or  of  the  guardian, 
perhaps  of  a  counsel  named  for  the  purpose.  The  practice  in  this 
case  is  pretty  well  free  from  trouble;  the  theoretical  difficulties,  how- 
ever, are  numerous;  there  are  foolish  people  who  do  not  wish  to  de- 
prive a  person  incapable  of  action  of  "the  disposition  of  his  own 
body"  and  would  rather  deprive  him  of  life  or  limb  than  amputate 

^  See  also  Treatment  of  Schizophrenia. 
'  Comp.  p.  209. 


THE  TREATMENT  OF  MENTAL  DISEASES  IN  GENERAL  225 

a  couple  of  gangrenous  toes  against  his  will.  The  reduction  of  a  dis- 
location, the  proper  treatment  of  a  fracture  naturally  do  not  belong 
to  the  "operations"  in  the  specified  sense;  this  is  not  true,  however,  of 
lumbar  punctures  which  require  considerable  skill.  Every  beginner 
does  well  in  these  matters  to  ascertain  exactly  the  customs  or  require- 
ments valid  in  his  district. 

The  interruption  of  pregnancy  ^  requires  special  indications.  In 
depressions  of  pregnancy  ^"  the  intervention  frequently  only  causes 
the  patients  severe  reproach  and  the  condition  is  aggravated,  while 
by  mere  waiting  with  sufficient  oversight  the  psychosis  is  regularly 
cured,  not  seldom  even  before  the  delivery.  However,  the  psychogenic 
depressions  or  situation  melancholias  of  girls  and  women  for  whom 
the  child  will  make  difficulties  are  theoretically  to  be  judged  differently. 
Such  diseases  can  naturally  be  cured  by  the  removal  of  the  cause; 
but  with  our  present  views  and  laws  this  cannot  be  a  sufficient  in- 
dication for  abortion.  Even  in  the  case  of  schizophrenia  and  oligo- 
phrenia in  spite  of  all  the  valid  reasons  that  may  be  advanced,  the 
sacrifice  of  the  child  is  only  decided  on  in  exceptional  cases.  It  is 
quite  different  in  the  case  of  early  and  severe  eclamptic  or  choreatic 
psychoses.  In  Germany  and  in  Catholic  districts,  according  to  the 
weight  of  opinion,  a  special  indication  (danger  of  a  diseased  progeny 
in  the  case  of  the  insane  and  idiots;  reaction  of  nursing  difficulties 
on  the  condition  of  the  mother)  does  not  properly  exist.  In  the 
Protestant  part  of  Switzerland  the  sensibilities  of  the  people  demand 
an  attitude  that  is  more  favorable  to  abortion  and  I  should  let  social 
considerations  count  with  the  legal.  Plain  legal  determinations  exist 
nowhere;  one  has  to  fall  back  on  local  and  customary  interpretations. 
At  all  events,  it  is  wise  not  only  to  weigh  carefully  all  the  circum- 
stances that  enter  into  consideration,  but  to  consult  an  experienced 
colleague.  Psychiatric  indications  of  premature  birth  are  more  rare 
and  simpler. 

^  Comp.  E.  Meyer,  Klinstliche  Unterbrechiing  der  Schwangerschaft  bei  Ps>'- 
chosen  (mit  Einschluss  der  Hysterie  und  Neurasthenie).  Med.  Klinik  191SL 
No.  7  u.  8. 

"  Cf.  pp.  210-211. 


CHAPTER  Xn 

THE  SIGNIFICANCE  OF  PSYCHIATRY 

The  frequenc}'  of  psychical  diseases  is  fairly  great.  Some  are  of 
the  opinion  that  about  two  per  thousand  of  the  population  is  pro- 
nouncedly insane;  but  this  does  not  include  those  "who  were  insane," 
the  mental  defectives,  who  are  more  than  again  as  numerous  as  the 
manifestly  insane,  and  most  epileptics.  And  it  is  not  to  be  doubted 
that  the  facts  exceed  by  far  the  estimate.  The  most  exact  enumera- 
tions give  about  one  percent  of  the  population  as  insane  and  oligo- 
phrenics. From  an  investigation  of  conscripts  Maier  goes  so  far  as 
to  raise  it  to  tw^o  percent.  In  its  insane  asylums  alone  Germany 
has  to  care  for  more  than  one  hundred  thousand  insane.  According 
to  statistics  obtained  by  the  National  Committee  for  Mental  Hygiene 
there  are  about  two  hundred  and  fifty  thousand  patients  in  the  hos- 
pitals for  the  insane  in  the  United  States.  New  York  State  supports 
about  forty-three  thousand  patients  in  its  State  Hospitals. 

But  the  estimated  pecuniary  loss  to  the  individual  is  not  less  than 
the  loss  to  the  people  generally.  The  paretic  who  has  made  a  position 
for  himself  and  has  a  family  and  then  permits  both  to  go  to  pieces 
is  a  frequent  occurrence,  the  same  is  seen  in  the  case  of  the  hebe- 
phrenic, who  for  a  half  century  has  to  be  maintained  at  the  expense 
of  the  family  and  the  state  and  who  retards  the  former  economically. 

Added  to  this,  is  the  peculiar  significance  of  insanity.  The  psyche 
is  the  essential  element  in  man,  not  only  from  a  religious  but  also 
from  the  viewpoint  of  natural  science.  Strong  muscles  and  solid  bones 
are  still  agreeable  attributes  for  those  who  have  them,  but  one  can 
direct  a  world  without  even  having  arms  and  legs,  while  a  slight 
disturbance  in  the  psychic  mechanism  can  change  the  strongest  man 
into  a  pitiable  object  of  care  or  into  a  dangerous  enemy  of  society. 
It  is  for  this  reason  that  the  psychoses  attain  their  social  importance 
much  more  than  other  diseases;  they  spread  their  harm  to  wider 
circles  and  they  rob  the  patient  himself  of  his  independence  in  alf 
his  relations  to  his  fellow  men.  They  falsify  or  destroy  his  social  posi- 
tion. He  can  no  longer  maintain  himself,  and  he  loses  his  qualifica- 
tions as  a  legal  subject.  What  was  said  applies  only  to  the  recognized 
insane,  but  if  the  insane  person  is  not  recognized,  the  consequences 

226 


THE  SIGNIFICANCE  OF  PSYCHIATRY  227 

are  often  more  serious  for  him,  above  all  for  the  family,  and  some- 
times for  society.  In  many  cases  unbearable  conditions  improve  as 
soon  as  the  diagnosis  is  made. 

Hence  the  great  and  sometimes  dreaded  import  of  psychiatric  ex- 
pert opinion. 

And  the  significance  of  psychological  and  psychopathological  con- 
siderations is  always  becoming  greater.  The  penal  code  whose  old 
standards  are  no  longer  adequate  for  modern  viewpoints  and  con- 
ditions, is  about  to  forge  new  weapons  for  itself  in  the  battle  against 
the  enemies  of  society.  This  can  only  be  accomplished  with  success 
if  the  conclusions  drawn  about  criminals  are  based  on  studies  and 
application  of  psychiatric  methods  of  investigation  and  psychiatric 
prognostication.  In  civil  jurisprudence  psychical  conditions  are  ever 
becoming  more  important;  the  psychological  problems,  which  the  anti- 
quated insanity  code  presents  to  the  judge  and  the  expert,  are  already 
so  large  and  so  numerous  that  the  profession  will  have  trouble  to 
meet  them.  A  jurisprudence  without  a  thorough  psychological  training 
is  becoming  more  and  more  insufficient. 

The  same  is  true  in  other  sciences.  Our  ethical  instincts  are  no 
longer  equal  to  the  modern  conditions  of  life  and  like  the  other  instincts 
become  inadequate  with  a  progressive  civilization;  indeed,  under 
certain  conditions  they  even  become  harmful,  (e.g.  the  instinct  of 
revenge).  Religions  which  since  Buddha  have  regarded  ethics  as 
their  domain,  no  longer  have  the  general  influence  that  they  had  in  the 
last  two  thousand  years.  A  conscious  ethics  can  naturally  spring  only 
from  the  intimate  study  of  the  social  psychology  of  man. 

History  is  at  last  beginning  to  become  psychological  and  conse- 
quently a  comprehending  science,  because  it  is  the  product  of  the 
human  psyche. 

Pedagogy  is  getting  ready  to  derive  benefit  from  a  penetrating  study 
of  the  soul  of  the  child. 

In  the  last  half  century  our  literature  has  become  immeasurably 
more  psychological,  even  though  in  this  respect  it  has  not  yet  caught 
up  with  the  French  and  Russian.  Poetic  compositions  and  especially 
their  creators,  themselves,  can  only  be  properly  understood  by  an 
extensive  psychological  study. 

A  particularly  fertile  field  scientificalty  and  practically  is  the 
borderland  between  the  normal  and  disease.  The  normal  and  average 
man  is  the  product  of  adaptation  to  conditions  and  must  consequently 
always  hobble  along  somewhat  behind  the  requirements.  He  dare 
not  conspicuously  develop  a  single  characteristic  at  the  expense  of 
others,  because  he  is  above  all  the  physical  forebear  of  the  future 


228  TEXTBOOK  OF  PSYCHIATRY 

generations  and  as  such  must  be  able  to  bequeath  in  proper  propor- 
tion all  psychical  gifts  needed  by  society.  But  civilization  is  fur- 
thered by  those  who  are  developed  in  a  one-sided  manner,  who  in- 
wardly and  outwardly  specialize  themselves,  who  carry  out  the  division 
of  labor,  and  by  those  who  are  not  sufficiently  adapted  to  be  satisfied 
with  everything  that  exists. 

But  while  the  lines  of  deviation  are  countless,  the  useful  pos- 
sibilities are  naturally  few.  Thus  the  bad  prophets,  the  clumsy  world 
reformers,  the  fanatic  partisans  who  are  inspired  by  all  sorts  of 
unrealizable  dreams,  and  those  who  are  really  regarded  as  sick  are 
and  will  continue  to  be  the  majority  of  the  abnormal.  To  recognize 
them  in  the  morbidity  of  their  inner  life  is  a  problem  that  is  prac- 
tically important,  that  could  contribute  materially  to  the  improvement 
of  our  public  affairs. 

The  study  of  race  and  mass  psychology,  which  is  dominated  by 
such  people,  should  complete  this  knowledge.  Psychopaths  and  in- 
sane, such  as  Mohammed,  Luther,  Loyola,  Rousseau,  Pestalozzi, 
Napoleon,  and  Robert  Meyer,  have  influenced  the  course  of  our  civ- 
ilization in  a  fateful  or  beneficent  way.  The  psychic  epidemics  from 
the  crusades  and  the  dances  of  St.  Vitus  to  the  twitchings  of  modern 
school  children,  and  the  numerous  sectarian  and  party  movements  in 
religion,  politics,  and  art,  all  represent  the  readily  discernible  peaks 
of  the  fluctuations  of  ideas,  in  which  the  psychic  life  of  races  expresses 
itself  and  from  which  the  achievements  of  individual  leading  spirits 
grow  as  advanced  pathfinders,  as  complements  or  as  negatives  to  the 
general  current. 

For  the  physician  a  psychological  training  is  nowadays  particularly 
necessary.  While  the  naive  practice  of  medicine  was  always  in  great 
part  psychic,  and  the  quack  even  yet  partly  heals  and  partly  shears 
his  patients  by  following  psychic  lines,  the  development  of  the  exact 
methods  of  modern  times  has  diverted  the  physician  from  psychical 
conceptions;  indeed,  as  Adolph  Meyer  expresses  it  it  has  engendered 
an  actual  "Psychophobia."  But  theory  and  practice  are  suffering 
severely  from  this,  when  one  side  of  a  man  is  neglected  and  to  be 
sure  it  is  the  one  which  through  ideas  and  affects  is  the  chief  regu- 
lator of  all  bodily  functions,  and  which  alone  decides  the  relation 
between  physician  and  patient.  The  good  practitioner  is  still  pre- 
ponderately  the  good,  though  usually  instinctive,  psychologist.  The 
origin  and  disappearance  of  "Neuroses"  goes  by  way  of  the  psyche. 
The  control  of  diseases  of  accidental  origin,  which  cost  the  exchequer 
millions,  and  which  make  permanent  cripples  of  many  people,  is  only 
possible  since  their  psychic  origin  has  been  grasped,  and  the  mani- 


THE  SIGNIFICANCE  OF  PSYCHIATRY  229 

festations  of  a  good  many  other  diseases  in  the  single  individual  are 
modified  and  modifiable  by  the  psyche.  The  usual  digestive  and 
menstrual  difficulties  are  in  large  part  entirely  psychogenic  diseases. 
Mental  hygiene  in  the  family  is  not  less  necessary  to  the  happiness  of 
mankind  than  physical  hygiene;  in  short,  a  complete  physician  must 
understand  the  complete  individual. 

Now  experience  has  shown  here  as  everywhere,  that  it  is  difficult, 
yes,  impossible  to  obtain  insight,  if  only  the  commonplace,  the  normal 
is  considered.  That  accounts  for  the  fact  that  psychology  in  the  past 
could  not  only  not  contribute  anything  to  all  these  purposes,  but  was 
positively  a  hindrance  to  better  insight.  Only  the  newer  schools  such 
as  those  of  Marbe  and  Stern  tend  in  this  direction.  Hence  what  is 
important  we  shall  only  recognize  from  the  study  of  the  growing 
psyche  of  the  child  and,  above  all,  from  the  aberrations  of  those 
already  developed  in  psychopathology.  At  this  time  one  of  the  most 
important,  if  not  the  most  important  path  to  a  knowledge  of  the  human 
soul  is  by  way  of  psychopathology. 


CHAPTER  Xm 

THE  INDIVIDUAL  MENTAL  DISEASES 

L— V.     THE  ACQUIRED  PSYCHOSES  WITH  COARSE  BRAIN 
DISTURBANCES.    THE  ORGANIC  SYNDROME 

Kraepelin  has  here  differentiated  injuries  and  diseases  of  the  brain 
and  for  practical  reasons  syphilitic  diseases  are  separated  from  the 
latter.  Among  the  syphilitic  conditions  again  the  most  important, 
paresis,  has  been  emphasized  because  of  its  historic,  symptomatic,  and 
practical  individuality.  With  the  senile  forms  and  the  real  Korsakoff 
disease  resulting  from  intoxication  (alcohol,  CO,  lead,  bacteria  toxins, 
etc.),  it  has  in  common  the  diffuse  reduction  of  the  brain  and  with 
this,  a  large  part  of  the  symptomatology.  These  three  forms  are 
thought  of  first  when  the  organic  psychoses  are  mentioned.  But  they 
include  also  the  various  forms  of  degenerations  of  the  nervous  system, 
such  as  the  glioses,  multiple  sclerosis,  cerebral  changes  in  tabes,  tumors, 
etc.  They  alone  have  in  common  the  "organic  syndrome,"  which  with 
a  one-sided  emphasis  of  the  memory  defect  was  also  designated  as  the 
Korsakoff  symptom  complex}  Naturally  it  can  also  be  found  in 
other  brain  diseases,  as  soon  as  they  result  in  a  diffuse  cortical  lesion. 
If  the  cortex  as  a  whole  is  only  functionally  damaged  by  a  trauma, 
these  symptoms  may  again  disappear — "curable  Korsakoff" — the  same 
is  true  in  an  intoxication  with  adjustable  anatomic  disturbances 
(delirium  tremens). 

Only  diffuse  disturl)ances  of  the  cortex  cause  a  real  weakening  of 
intelligence,  whereas  certain  affective  disturbances  can  already  mani- 
fest themselves  in  cortical  brain  lesions,  most  frequently  when  it 
affects  the  thalamic  region.  Irritability  and  a  tendency  to  all  sorts  of 
temporary  moodiness,  again  in  the  direction  of  anger  and  rage,  are 
the  most  common  persistent  manifestations  in  most  focal  lesions  of 
the  brain,  but  in  diffuse  disturbances  as  well  as  in  lesions  in  the 
thalamic  region,  the  general  affective  lability  would  seem  to  be  more 
marked. 

^Korsakoff's  disease  is  really  a  toxic  neuritis  of  the  peripheral  and  central 
nervous  system.  The  name  was  then  incorrectly  transferred  to  other  diseases 
showing  similar  memory  disturbances. 

230 


THE  INDIVIDUAL  MENTAL  DISEASES  231 

THE  ORGANIC  SYNDROME 

The  diffuse  reduction  of  the  functions  of  the  cortex  results  in  definite 
symptoms,  which  only  vary  in  detail  according  to  the  circumstances 
and  the  diseases. 

Memory:  -  All  things  being  equal,  the  fresher  an  engram,  the 
worse  is  recollection  ranging  up  to  complete  absence  of  impressibility, — 
the  older  it  is,  the  less  the  memory  is  disturbed.  Patients  who  evince 
a  greater  poverty  of  thoughts  often  fill  their  memory  gaps  with 
(real)  despairing  confabulations,  while  the  more  productive  ones, 
going  beyond  this,  revel  in  spontaneous  pseudo-recollections.  Transi- 
tory confusions  or  other  disturbances  of  consciousness  (attacks  of  all 
kinds)  are  frequently  followed  by  amnesias. 

The  extent  of  associations  simultaneously  possible  is  restricted.^ 
The  choice  of  the  latter  is  chiefly  decided  by  the  affects,  that  is,  by 
the  momentary  strivings.  One  of  the  first  results  of  this  is  an  absence 
of  the  critical  faculty  and  a  disturbance  of  judgment.  Recall  the 
paretic  who  jumps  from  a  high  window  to  get  a  cigar  butt,  and  the 
one  who  steals  an  object  when  everyone  is  looking  and  then  care- 
fully conceals  it.  Another  paretic  stole  a  barrel  of  wine  from  in 
front  of  a  wine  shop  in  bright  daylight,  and  rolled  it  homewards; 
when  he  became  tired,  he  begged  two  policemen  to  help  him,  and 
they  went  so  far  in  their  good  nature  as  to  give  him  his  way.  A 
paretic  physician  threatened  to  run  away  from  us;  he  said  that  he 
could  accomplish  this  very  easily  in  the  following  way:  he  would 
go  walking  with  us,  and  then  he  would  step  aside  for  a  moment 
and  not  return.  When  the  organic  patient  in  a  state  of  euphoria 
comes  to  an  institution  and  finds  a  nice  room  and  a  friendly  attitude, 
he  very  frequently  overlooks  the  entire  internment  with  its  element 
of  force,  and  declares  that  he  will  remain  there  for  such  and  such 
a  time.  A  paretic  finds  an  old  bag,  cuts  up  several  new  ones  to 
mend  it,  then  gets  the  idea  to  make  it  big  enough  to  reach  the  ceil- 
ing. Patients  at  the  height  of  their  disease  only  exceptionally  acquire 
wisdom  through  experience.  In  every  institution  one  is  well 
acquainted  with  the  variations  of  the  paretic,  who  for  several  years 
has  greeted  the  physician  at  every  visit  with  the  words:  "Next  Tues- 
day my  wife  will  come  and  take  me  away." 

Complicated  pictures  can  sometimes  no  longer  be  grasped  in  their 
context;  the  patient  counts  up  details  and  in  this  respect  then  reminds 
one  of  imbeciles. 

'  Cf.  p.  100  and  following. 
'Cf.  p.  74. 


232  TEXTBOOK  OF  PSYCHIATRY 

The  various  intellectual  abilities  do  not  disappear  uniformly,  but 
at  present  no  other  rule  can  be  stated  except  that  especially  developed 
and  practiced  abilities  escape  the  general  deterioration  the  longest. 
The  senile  bookkeeper  can  be  markedly  demented  in  all  other  direc- 
tions and  yet  surpass  many  a  healthy  person  in  addition.  A  paretic 
physician,  who  had  previously  made  quite  a  name  for  himself  as  a  chess 
player,  when  in  all  other  respects  he  seemed  completely  childish,  could 
still  announce  to  a  less  skilled  player  at  the  opportune  moment:  "In 
ten  moves  I  will  checkmate  you  on  this  particular  square,"  and  he 
was  nearly  always  right. 

The  psychic  processes  are  usually  more  or  less  retarded,  even  aside 
from  the  torpid  conditions  evidently  directly  based  on  the  disease 
process.  But  the  retardation  can,  in  certain  respects,  be  over-com- 
pensated by  manic  moods  with  their  rapid  succession  of  ideas.  Some- 
times the  patients  evince  distinct  difficulty  in  passing  from  one  topic 
to  another.  In  the  later  stages  the  tendency  to  perseveration  exists, 
in  severe  cases  so  strongly,  that  a  patient,  for  example,  answers  the 
most  varied  questions  about  his  personal  details  with  "61,"  after  he 
has  given  the  year  of  his  birth  with  this  number.  Intercurrent  stronger 
associative  disturbances  are  the  bases  of  the  deliria  and  states  of 
confusion. 

Of  the  disturbances  of  euphoria  those  individual  concepts  are 
naturally  most  strongly  affected  which  are  in  themselves  difficult  of 
access,  indefinite,  and  hard  to  determine.  In  place  of  them  the  patients 
reproduce  simple,  vague  and  general  ideas  such  as:  "building"  for 
sunmier  house,  "man"  for  carpenter.  Their  answers  to  questions  are 
also  characteristically  indefinite  as  shown  by  the  following:  "Where 
do  you  come  from  now?"  "I  have  come  forward  from  in  back  there." 
"Where  is  our  institution?"  "Why,  it  is  in  this  city."  Such  answers 
are  not  given  in  the  manner  of  intentional  evasion  but  with  a  good 
natured  sincerity.  The  patients  are  evidently  satisfied  with  them  and 
expect  the  questioner  to  feel  the  same  about  them.  Very  often  the 
form  of  the  answer  is  influenced  by  the  mood:  "In  what  ward  are 
we  now?"  "In  a  nice  one."  "What  sort  of  people  are  they?"  "The 
right  sort  of  people."  In  other  cases  a  more  or  less  conscious  em- 
barrassment is  shown,  which,  however,  does  not  really  change  the  char- 
acter of  the  answer:  in  the  case  of  questions  concerning  the  date,  the 
patients  have  not  seen  the  newspaper  or  the  calendar  just  of  today, 
or  refusing  to  recognize  the  significance  of  the  question,  they  turn  to  a 
companion  and  ask  him  to  give  the  answer,  etc.  This  symptom  also  is 
especially  marked  in  cases  of  senility. 

The  affectivity  is   labile;   it  manifests  itself  more   strongly   and 


THE  INDIVIDUAL  MENTAL  DISEASES  233 

quickly  than  normal  (emotional  incontinence) :  but  emotional  excite- 
ments pecter  out  more  readily,  either  spontaneously  or  because  the 
patient  is  led  to  think  of  something  else.  In  the  latter  case,  too,  a 
lively  mood  may  be  supplanted  by  another  without  leaving  any  trace, 
often  in  a  few  seconds;  the  actual  emotion  dominates  the  patient 
absolutely.  Trifles  make  him  happy  or  desperate.  A  paretic  woman 
seriously  attempted  suicide  because  her  husband  was  late  for  a  meal. 
To  the  extent  that  the  insight  for  complicated  relations  is  absent, 
these,  naturally,  can  no  longer  become  accentuated  with  feeling.  The 
feeling  reaction  is  easily  restricted  to  certain  fields  also  by  the  de- 
crease of  associations,  and  the  patients  appear  indifferent,  although  the 
defect  is  not  really  in  the  affective  element.  A  general  brain  torpor 
naturally  expresses  itself  also  in  the  affectivity;  on  the  other  hand, 
other  patients  have  an  exaggerated  general  excitability,  and  conse- 
quently also  an  affective  excitability.  The  egotistic  interests  are 
naturally  among  those  most  difficult  to  suppress.  As  these  patients 
cannot  easily  or  at  all  think  of  other  corrective  ideas,  especially  con- 
trast ideas  in  conjunction  with  their  egotistic  ones,  many  appear 
egotistic  in  their  thoughts,  feelings  and  acts.  This  is  particularly  evi- 
dent in  the  simple  senile  forms ;  while  in  erethic  and  manic  conditions, 
which  occur-  especially  in  paresis,  the  more  varied  change  in  thinking 
over-compensates  this  tendency. 

It  is  usually  said  that  the  ethical  feelings  of  the  organic  patients 
deteriorate  early  and  very  markedly.  I  believe  this  is  wrong.  Some  of 
these  patients,  no  doubt,  commit  all  sorts  of  crimes,  but — to  the  ex- 
tent that  they  were  previously  decent — according  to  my  experience 
they  commit  them  because  they  no  longer  have  an  insight  into  the 
entire  situation  and  its  consequences.  If  they  can  be  made  to  compre- 
hend what  they  have  done,  they  regret  it  in  the  normal  way.  If 
they  previously  had  anti-social  tendencies,  the  disappearance  of  in- 
hibitions naturally  permits  these  to  become  more  easily  dangerous. 

The  cooperation  of  this  labile  affectivity  with  the  restricted  re- 
flective ability  makes  purposeful  action  impossible.  Tenderness,  con- 
sideration, tact,  piety,  aesthetic  sensibility,  sense  of  duty,  sense  of 
right,  feeling  of  sexual  shame — all  these  may  fail  at  any  moment,  even 
when  they  are  present.  Any  sort  of  impulses  from  within  and  without 
are  translated  into  action  without  any  restraint. 

Acute  manic  and  melancholic  moods,  lasting  for  months  and  some- 
times longer,  appear  frequently.  The  mood,  chronic  throughout  the 
entire  course,  may  also  be  a  morbidly  euphoric  or  depressive. 

Corresponding  to  this  condition  of  affectivity  and  the  restriction 
of  associations,  the  positive  as  well  as  negative  suggestibility  is  height- 


234  TEXTBOOK  OF  PSYCHIATRY 

ened;  on  the  one  hand  such  people  are  easily  influenced  and,  on  the 
other  hand,  they  are  stubborn. 

Apperception  is  retarded  and  unclear.  The  patients  require  more 
time  to  recognize  pictures  and  often  deceive  themselves  anyway ;  fail- 
ures to  recognize  are  sometimes  caused  by  perseverations.  Things  read 
are  easily  perceived  imperfectly  and  incorrectly.  Questions  to  the 
patient  often  must  be  repeated  and  are  sometimes  answered  in  the 
sense  of  the  previous  trend  of  thought. 

Orientation  as  to  time  and  space  often  also,  the  autopsychic,  is 
disturbed.  The  patients  lack  the  "inner  clock."  Many  of  these 
patients  no  longer  differentiate  whether  they  or  others  are  being 
spoken  to,  which  is  also  a  part  of  disturbed  orientation.  When  pre- 
sented at  the  chnic,  for  example,  many,  like  patients  in  alcoholic 
delirium,  answer  regularly,  when  one  speaks  to  the  audience. 

Attention,^  aside  from  the  restricted  extent,  is  made  diflBcult; 
this  is  seen  more  in  the  habitual  and  the  passive  than  in  the  maximal 
and  the  active  attention.  The  intensity  of  the  latter  may  be  normal, 
even  if  the  extensity  has  already  suffered  severely.  Sometimes 
vigility  is  reduced  at  the  same  time  with  tenacity. 

If  Delusions  are  present,  they  obtain  as  a  rule  the  character  of 
senselessness  in  the  severe  cases.  Among  the  depressive  delusions  one 
observes  commonly  exaggerated  ideas  referring  to  diseases;  the  delire 
d'enormite  and  nihilism  when  present  are  especially  characteristic. 

Hallucinations  usually  affect  sight  and  hearing.  Corresponding  to 
the  brain  process  other  kinds  of  parasthesias  also  occur,  which,  under 
certain  circumstances,  attain  a  similarity  with  real  (body-)  hallucina- 
tions. This  is  usually  brought  about  through  misinterpretation 
in  a  state  of  delirium.  Many  of  our  patients  are  excited  and 
hallucinate  at  night,  while  during  the  day  they  are  quiet  or  actually 
sleep. 

With  depressive  patients,  screaming  throughout  the  night,  lasting 
for  months,  is  not  rare,  and  generally,  stereotyped  whining  and  com- 
plaining are  nowhere  more  pronounced  than  here. 

Severe  anxiety  attacks  with  senseless  or  confused  reactions,  push- 
ing away,  clinging,  brutal,  and  often  clumsy  attempts  at  suicide,  hiding 
away,  hitting  at  random,  etc.,  are  in  part  results  of  the  brain  disease, 
and  in  part  probably  results  of  disturbances  of  the  circulatory 
apparatus;  at  all  events  they  are  most  frequently  seen  in  sufferers 
from  .arteriosclerosis. 

Besides,  various  kinds  of  delirious,  perhaps  also  of  tmlight  states 
occur,  which  under  no  circumstances  manifest  the  same  genesis.    We 

*Cf.p.  134. 


THE  INDIVIDUAL  MENTAL  DISEASES  235 

find  them  as  intercurrent  symptoms  of  paresis;  in  arteriosclerotic 
psychosis  especially  after  the  inception  of  diffuse  softening,  etc. 

The  organic  psychoses  are  usually  accompanied  by  phynical  symp- 
toms,  which  are,  in  part,  the  result  of  the  brain  affection  (paralyses, 
trophic  disturbances),  in  part  concomitant  manifestations  (senile 
marasmus,  neuritis).  An  irregular  coarse  tremor,  especially  of  the 
hands  and  the  organs  of  speech,  is  most  constant. 

As  physical  symptoms  one  often  designated  also  the  "nervous" 
manifestations  which  can  mark  the  beginning  of  every  organic  in- 
sanity. Among  these  we  have:  pressure  in  the  head,  headache, 
parasthesias,  flickering  of  the  eyes,  buzzing  in  the  ears,  etc.  Later 
they  are  in  part  concealed  by  the  deeper  psychotic  symptoms  or  in 
delirious  conditions  they  are  misinterpreted  as  illusions  and  delusions 
referring  to  the  body. 

The  disturbance  of  memory  is  most  often  characteristic  of  the 
simple  forms  of  dementia  senilis.  Here  one  sees  cases  in  which  the 
limits  of  absence  of  memory  may  be  determined  to  sonie  extent.  For 
instance,  the  patient  does  not  remember  anything  that  occurred  in  this 
century.  After  a  while  the  memory  gap  extends  back  to  the  nineties 
of  the  last  century,  then  to  the  eighties,  etc.  If  only  memories  of 
youth  are  present,  they  often  have  a  greater  freshness  than  under 
normal  conditions;  they  may  even  attain  an  hallucinatory^  vividness 
so  that  the  patients  believe  they  live  over  scenes  which  in  reality  took 
place  seventy  years  ago.  In  arteriosclerotic  forms  irregular  fluctua- 
tions of  memory  disturbance,  both  as  regards  content  and  time,  readily 
occur.  In  paresis  the  difference  in  the  ability  to  recall  earlier  and 
fresher  experiences  is  sometimes  not  so  striking  as  in  the  senile  forms, 
but  it  can  be  invariably  demonstrated,  even  though  sometimes  it  first 
appears  only  when  the  dementia  becomes  deeper.  Alcoholic  Korsa- 
koff's disease  when  it  is  acute  usually  shows  at  first  a  well  defined 
limit  of  the  ability  to  recall  at  the  beginning  of  the  disease;  the  patients 
have  at  their  disposal  nothing  that  occurred  since ;  what  occurred  pre- 
viously they  recall  pretty  completely.  However,  this  demarkation 
becomes  blurred  rather  quickly,  in  that  earlier  experiences  also  are 
not  remembered  at  all  or  incorrectly.  In  the  magic  form  of  paresis 
and  alcoholic  Korsakoff,  confabulations  often  appear  altogether  with- 
out any  restrictions.  In  many  torpid  forms  of  the  senile  psychoses 
confabulations  are  almost  absent.  Other  things  being  equal  it  in- 
creases and  decreases  with  excitement  and  activity. 

The  absence  of  the  critical  faculty  appears  to  be,  on  the  whole. 
more  pronounced  in  paresis  than  in  the  senile  forms,  where  the  per- 
sonality with  its  strivings  in  relation  to  the  elementar\^  disturbance 


236  TEXTBOOK  OF  PSYCHIATRY 

is  often  better  preserved,  to  the  extent  that  a  miserly  old  man,  for 
example,  is  not  easily  talked  into  making  gifts,  etc.  The  uncertain 
answers,  which  are  to  disguise  the  dearth  of  ideas,  are  found  most 
frequently  and  in  a  most  pronounced  form  in  the  simple  senile  dements. 
Coarse  brain  lesions  lead  most  readily  to  marked  perseverations. 

The  productivity  of  the  delusions  in  manic  paresis  is  enormous  but 
in  the  other  forms  it  is  very  limited.  Moreover  the  phantasy  forma- 
tion in  paresis  and  in  alcoholic  Korsakoff  is  usually  very  vivid,  else- 
where it  is  rather  reduced. 

The  lability  of  the  affects  also  occurs  frequently  as  the  result  of  a 
hemorrhage  in  the  thalamic  region;  it  may  then  remain  as  an  isolated 
symptom,  in  that  the  intelligence  is  not  affected  at  all  or  only  after 
months  and  years.  In  paresis  there  is  a  marked  tendency  to  euphoric 
moods,  and  in  the  senile  forms  to  depressive  moods.  Alcoholic  Korsa- 
koff cases  are  usually  very  euphoric  for  a  long  period. 

Apperception  is  often  preserved  much  longer  in  the  simple  senile 
forms  than  in  paresis. 

Certain  variations  of  the  organic  forms  are  often  determined  by 
congenital  predisposition  of  the  brain ;  thus  emotional  people,  especially 
members  of  families  with  manic  depressive  tendencies,  more  readily 
have  affective  forms  of  paresis  and  of  the  senile  psychoses;  indeed, 
even  the  depressive  or  manic  dispositions  become  particularly  marked 
by  the  addition  of  the  brain  disease;  paranoid  forms  occur  in  patients 
who  have  always  been  distrustful  and  inclined  to  false  interpretations, 
while  schizophrenic  forms  in  those  who  originally  belong  to  the  schizoid 
type,  etc.  Nevertheless  the  kind  of  process  has  its  influence  also; 
thus  paresis  inclines  to  euphoric  states,  arteriosclerosis  to  depressive 
and  anxiety  states;  delusions  of  stealing  is  an  organic-senile  mani- 
festation, not  a  constitutional  symptom,  etc. 

Corresponding  to  the  underlying  brain  disease  the  outcome  of 
organic  psychoses  is  usually  fatal.  Intoxication  psychoses,  like  Korsa- 
koff, can  improve  more  or  less,  or  after  a  slight  improvement  remain 
essentially  stationary.  In  spite  of  a  course  which  is  progressive  on 
the  whole,  remissions  in  paresis  and  in  the  arteriosclerotic  forms  may 
go  very  far;  in  the  latter  the  particular  improvements  can  also  last 
only  a  few  days  or  hours;  but  then  they  are  usually  more  frequent 
and  constitute  an  important  element  of  the  entire  picture;  this  is 
probably  the  only  occasion  on  which  one  can  properly  speak  of  "Lucid 
intervals."  The  prognosis  of  particular  senile  diseases  will  be 
discussed  later. 

A  differential  diagnosis  of  the  organic  psychoses  is  not  easy  in 
the  beginning.     The  disease  must  already  have  attained  a   certain 


THE  INDIVIDUAL  MENTAL  DISEASES  237 

height  before  a  large  part  of  the  disturbances  mentioned  become  evi- 
dent. Orientation,  for  example,  in  patients  whose  sensorium  is  clear 
is  only  falsified  in  the  more  advanced  stages  of  dementia.  But  it  may 
also  happen  that  intelligent  witnesses  in  court  pronounce  a  man  en- 
tirely capable  of  action  who,  literally,  mistakes  niglit  and  day  and 
wants  to  go  to  his  office  at  eleven  o'clock  at  night  and  closes  his  office 
in  the  forenoon.  On  the  other  hand  in  senile  dementia  the  difficulty 
lies  in  the  fact  that  normal  senility  indicates  similar  symptoms:  One 
does  not  know  at  what  stage  of  memory  disturbance  or  of  affective 
lability  one  should  count  the  beginning  of  the  disease.  In  these  cases 
practical  reasons  must  sometimes  serve  as  criteria. 

If  a  pronounced  melancholic  condition  exists,  then  a  petty  reaction 
to  minor  affairs  like  a  belated  meal,  or  a  striking  affective  distraction, 
perhaps  by  a  joke,  point  to  organic  lability. 

More  important  still  is  the  nonsense  of  the  delusions  and  here  espe- 
cially the  form  of  nihilism  and  of  the  Delire  d'enormite.  Disturbances 
of  orientation  may  naturally  only  be  evaluated  in  cases  where  it  occurs 
in  a  clear  sensorium.  Nocturnal  excitements  with  sleeping  by  day 
must  be  weighed  carefully  because  they  also  occur  elsewhere,  e.g. 
sometimes  in  schizophrenia.  Slow  functioning  of  the  psychic  proc- 
esses, even  though  of  a  somewhat  different  kind,  occurs  in  epilepsy, 
where  one  also  sees  blurred  perception  and  perseveration. 

States  of  organic  unclearness  can  be  recognized  most  conspicuously 
by  a  good  affective  rapport  with  a  declining  intellectual  rapport;  this 
is  differentiated  from  epilepsy  by  the  fact  that  fluctuations  of  emotional 
reaction  readily  occur.  Usually  the  patient  is  eagerly  occupied  with 
any  obviously  foolish  action,  which  is  to  be  designated  as  imaginary, 
since  it  is  not  based  on  hallucinations.  The  patient  endeavors,  for 
example,  to  fold  the  comforter,  if  he  succeeds,  which  he  rarely  does, 
or  if  we  fold  it  for  him,  he  nevertheless  continues  in  exactly  the  same 
way  to  fuss  around  with  it.^ 

Frequently  while  the  diagnosis  of  the  organic  disease  is  not  yet 
possible,  the  specific  manifestations,  especially  physical  symptoms  like 
neuritis,  pupillary  and  speech  disturbances  (Korsakoff,  paresis)  permit 
a  definite  diagnosis  of  the  special  psychosis.  More  frequently  the 
reverse  holds  true;  that  is,  the  "organic  psychosis"  can  be  generally 
recognized  while  the  specific  symptoms  of  a  definite  form  are  still  lack- 
ing. The  latter  is  especially  true  in  view  of  the  fact  that  there  are 
also  organic  psychoses  resulting  from  brain  diseases  which  are  not 
yet  known. 

An  important  means  of  recognizing  and  differentiating  organic  dis- 
"Comp.  presbyophrenic  delirium,  pages  290  and  294. 


238  TEXTBOOK  OF  PSYCHIATRY 

turbances  of  the  central  nervous  system  is  the  examination  of  the 
cerebrospinal  fluid.  The  lumbar  puncture  also  has  therapeutic  signifi- 
cance in  various  diseases.  But  one  must  be  cautious,  especially  in  brain  ' 
tumors,  because  of  the  danger  that  the  medulla  oblongata  may  be 
pressed  into  the  occipital  foramen,  and  in  traumatic  neuroses,  in  which 
new  complaints  may  be  attached  to  the  operation. 

The  technique  of  puncturing  should,  in  the  interest  of  the  patient, 
be  learned  by  practical  demonstration  and  initial  practice  under  super- 
vision. To  refresh  the  memory  the  following  points  are  mentioned 
here:  If  a  line  is  drawn  on  the  patient's  back  connecting  the  two 
crests  of  the  ileum,  then  directly  over  and  under  this  line  one  finds 
the  space  between  the  third  and  fourth  and  the  fourth  and  fifth  lumbar 
vertebra^,  respectively,  one  of  which  is  selected  for  the  puncture.  This 
is  the  region  of  the  cauda  equina,  so  that  injury  of  the  cord  is  impos- 
sible. Disinfection  of  the  region  must  be  most  carefully  done.  The 
puncture  needle  should  be  at  least  ten  cm.  long  and  as  thin  as  possible ; 
the  elastic  instruments  of  platiniridium  are  the  best.  In  the  insane 
it  is  often  an  advantage  to  puncture  them  while  in  a  sitting  position, 
because  it  is  easier  to  hold  them,  and  because  they  are  usually  less 
excited  than  when  they  are  put  in  a  reclining  position;  in  both  cases 
the  most  important  item  is  the  very  decided  flexion  of  the  spinal  column 
("hump  back")  because  then  the  inter-vertebral  spaces  open;  but  the 
spinal  column  must  not  be  turned  laterally  because  the  location  of  the 
spinal  canal  is  then  more  difficult  to  find.  The  sitting  patient  is  best 
placed  so  that  he  sits  backwards  on  a  chair  and  throws  his  arms  around 
its  back;  an  attendant  kneels  in  front  of  him  and  holds  his  legs  sym- 
metrically upwards.  The  puncture  is  made  either  in  the  middle  line 
directly  under  the  third  or  fourth  lumbar  spinous  process  which  is 
located  with  the  finger  of  the  free  hand.  The  direction  of  the  puncture 
should  be  slightly  oblique  tending  upwards;  the  lateral  method  pene- 
trates a  little  deeper,  one  cm.  beside  the  middle  line.  In  the  first  case 
one  has  the  great  advantage  that  one  must  puncture  directly  in  the 
middle  line  without  a  lateral  deviation,  while  in  the  lateral  puncture 
the  correct  estimate  of  the  angle  requires  more  practice;  on  the  other 
hand,  in  the  median  puncture  one  must  go  through  the  hardest  part 
of  the  ligaments  which  occasionally  may  deceive  with  a  resistance 
equal  to  that  of  bone.  Frequently  the  puncture  is  made  too  deep; 
then  a  slow  withdrawal  of  the  needle  suffices  to  permit  the  outflow 
of  the  liquor  which  had  apparently  not  been  reached. 

For  purely  diagnostic  purposes  six  to  ten  ccm.  should  be  withdrawn ; 
in  cases  of  paresis  one  can  usually  go  a  little  higher  without  disagree- 
able consequences.     Rapid  decline  of  high  pressure  even  after  a  slight 


THE  INDIVIDUAL  MENTAL  DISEASES  239 

emptying  indicates  clanger  because  of  defective  communication  between 
the  cerebral  fluid  and  spinal  canal. 

If  one  wants  to  measure  the  pressure  of  the  liquor,  one  must  nat- 
urally do  that  first  and  with  the  patient  lying  on  his  side.  One  at- 
taches to  the  needle  a  sterile  tube  of  small  calibre  with  a  glass  attach- 
ment, lifts  it  as  long  as  the  fluid  in  the  glass  attachment  rises,  then 
one  measures  the  height  from  the  point  of  puncture  with  a  scale  held 
alongside.  The  normal  height  varies  between  90  and  140  mm.  H^O. 
In  case  of  very  high  pressure  the  withdrawal  should  be  retarded  and 
ended  before  it  has  come  to  the  normal  height.  After  the  puncture 
the  patient  should  lie  in  bed  for  24  hours  in  about  a  horizontal  position. 
If  there  is  slight  temperature  or  headache  or  heaviness  in  the  head, 
as  occasionally  happens,  he  should  remain  in  bed  two  or  more  days 
and  take,  perhaps,  some  pyramidon  (0.2  to  0.3  per  dose). 

In  the  normal  person  the  fluid  is  clear  and  colorless;  intermixtures 
of  blood  resulting  from  the  puncture  settle  quickly  when  permitted 
to  stand.  (Sera  containing  blood  are  naturally  useless  for  the  Wasser- 
mann  reaction.)  In  yellowish  discolorations  that  do  not  come  from 
bleeding  of  the  puncture,  bleeding  of  the  brain  should  be  thought  of 
especially,  then  of  cerebral  inflammation  and  pachymeningitis.  Count- 
ing the  celhilar  elements  of  the  fluid  must  be  done  as  soon  as  possible, 
as  otherwise  they  turn  to  sediment;  it  is  best  done  with  the  blood  cell 
chamber  as  modified  by  Fuchs-Rosenthal,  which  has  a  depth  of  0.2  mm. 
instead  of  0.1  mm.;  as  a  stain,  for  example,  one  can  use  Methylviolet 
0.2,  Acid.  acet.  glac.  1.0,  Aq.  dest.  50.0.  The  normal  number  is  0  to  5 
cells  in  the  cubic  millimeter;  6  to  10  is  suspicious;  what  exceeds  this 
number  may  be  considered  pathological.  A  psychosis  with  an  increase 
of  the  cells  is  generally  paresis. — If  one  w^ants  to  differentiate  the  in- 
dividual cell  forms,  one  had  better  stain  according  to  well  known 
methods  after  the  fluid  is  centrifuged.  Plasma  cells  found  in  a 
psychosis  usually  indicate  paresis. — Still  more  important  is  the  Wasser- 
mann  reaction  of  the  serum,  in  which  the  evaluation  with  different 
doses  of  liquor  is  frequently  necessary.  In  paresis  the  reaction  is 
usually  strong;  in  lues  of  the  central  nervous  system  it  is  frequently 
weaker.*'  Chemically,  Nonne's  "Phase  I"  is  significant:  About  1  to 
2  ccm.  of  the  fluid  are  mixed  with  an  equal  amount  of  a  saturated 
aqueous  solution  of  ammonium  sulphate,  not  warmed:  In  central 
syphilogenous  diseases  a  discoloration  or  at  least  an  opalescence  ap- 
pears, which  proves  the  increased  presence  of  globulin  and  nuclein. 
If  it  is  then  boiled  the  remaining  albuminous  elements  precipitate 
(Nonne's  "Phase  11") ,  but  the  latter  examination  is  better  made  with 

"See  page  248. 


240  TEXTBOOK  OF  PSYCHIATRY 

Nissl's  graduated  tube,  in  which  2  ccm.  of  the  fresh  fluid  is  replaced  by 
1  ccm.  of  the  common  Esbach  reagent  and  then  centrifuged  for  one 
half  to  three  quarters  of  an  hour ;  the  precipitate  gathers  at  the  bottom 
of  the  tube  and  can  be  removed;  the  normal  liquor  hardly  contains 
more  than  0.2  to  0.35%  of  albumin;  in  pathological  conditions  a  two- 
fold or  greater  increase  frequently  occurs. 

Phase  I  is  regularly  positive  (opalescence)  in  paresis,  congenital 
syphilis,  in  extra  medullary  tumors,  a  little  rarer  in  tabes  and  other 
luetic  forms  of  the  central  nervous  system,  only  in  some  cases  of  brain 
abscess  and  other  diseases  of  the  brain,  spinal  cord,  and  its  meninges. 

According  to  Kajka  ^  the  chemical  diagnosis  may  be  carried  fur- 
ther. The  Globulines,  which  already  separate  when  a  28%  saturated 
solution  of  ammonium  sulphate  is  added,  indicate  acute  meningeal 
inflammation  but  do  not  exclude  tubercular  or  luetic  processes.  The 
euglobulins  (fibrinogen,  fibrinoglobulin) ,  whose  presence  proves  paresis, 
still  separate  with  reagents  saturated  to  33%.  The  pseudoglobulins 
only  occur  in  chronic  lues  cerebri  and  only  become  visible  with  the 
application  of  a  solution  saturated  to  40%.  ^-L^ 

I.     INSANITY  IN  INJURIES  TO  THE  BRAIN  «  \ 

In  the  confusing  mass  of  external  pictures  resulting  from  brain 
injuries  one  still  misses  a  systematic  viewpoint.  A  few  types  that  I 
mention,  following  Kraepelin,  may  give  an  indication  of  what  occurs 
in  this  connection. 

Concussion  of  the  brain  with  its  symptoms  of  unconsciousness, 
collapse,  vomiting,  etc.,  is  familiar  to  physicians  from  the  study  of 
surgery. 

Traumatic  delirium  or  commotion  psychosis.  A  delirious  state 
sometimes  follows  directly  after  the  accident  or  brain  concussion  in 
which  disturbance  of  memory  of  the  organic  type,  or  traumatic  in  un- 
injured brains  of  curable  Korsakoff,  is  usually  plainly  recognizable; 
sometimes  it  is  connected  with  nervous  symptoms  like  headache,  dizzi- 
ness and  with  focal  symptoms  that  do  not  always  indicate  a  tangible 
anatomic  brain  injury.  The  state  of  affectivity  varies.  The  disease 
usually  lasts  only  a  few  hours  or  days,  occasionally  several  weeks, 
the  last  especially  when  it  has  developed  only  after  days  or  weeks 
after  the  trauma.  Later  one  observes  usually  a  lack  of  memory  with 
a  tendency  to  retroactive  amnesia. 

'Munch.    Med.  W.  S.  1915,  p.  105. 

*  Besides  Kraepelin,  comp.  Schroder,  Geistesstorungen  nach  Kopfverletzungen, 
Enke,  Stuttgart  1915. 


THE  INDIVIDUAL  MENTAL  DISEASES  241 

As  transitional  states  during  improvements,  and  more  frequently  as 
a  chronic  state,  that  can  attach  itself  to  the  trauma  immediately  or 
after  a  longer  latent  period  even  without  a  commotion  psychosis,  we 
notice  different  pictures  of  traumatic  states  of  weakness.  Common 
to  most  of  them  are  rapid  exhaustion,"  irritability,  tendency  to  spon- 
taneous and  reactive  moods,  up  to  the  most  intense  anger,  which  is 
in  part  labile  and  in  part  of  a  more  torpid  persistent  affect;  more 
rarely  we  notice  a  stupid  euphoria  with  a  mania  for  joking  (Moriaj. 
Not  rarely  epileptic  attacks  appear  in  which  the  typical  epileptic 
dementia  may  occur  (traumatic  epilepsy).^"  Pictures  similar  to  Cata- 
tonia can  last  for  a  long  time.  Even  after  a  long  time  subdural  or 
cerebral  bleedings  with  the  consequent  manifestations  can  occur. 

Not  very  rarely  milder  injuries  to  the  brain  cause  indefinite  symp- 
toms that  give  the  appearance  of  a  neurosis. 

In  children  injuries  to  the  brain  readily  lead  to  idiocy,  especially 
to  the  irritable  forms  with  moods. 

Berger^^  differentiates  (1)  commotion  psychosis,  (2)  traumatic  de- 
mentia, and  (3)  traumatic  twilight  state.  He  divides  commotion 
psychosis  into  (1)  hallucinatory  confusion,  (2)  those  with  the  Korsa- 
koff (=organic)  symptom,  (3)  those  with  a  manic  tinge,  (4)  those 
with  catatonic  symptoms. 

The  treatment  of  these  conditions  unfortunately  is  not  very  suc- 
cessful. In  the  delirious  forms  the  only  thing  that  can  be  done  is  to 
await  recovery  and  protect  the  patient  from  himself.  In  the  chronic 
forms  it  is  important  to  abstain  from  alcohol  which  enhances  the  symp- 
toms and  causes  excitement.  It  should  also  be  kept  in  mind  not  to 
give  such  people  cocaine  injections  (dentist!)  because  permanent 
epilepsies  may  be  released  as  a  result.  The  excision  of  a  scar  from 
the  brain  (more  frequently  from  the  meninges),  leaving  perhaps  an 
opening  as  a  pressure  vent,  is  said  sometimes  to  effect  a  cure  especially 
in  the  epileptic  forms;  perhaps  more  frequently  the  same  may  be 

®  Under  certain  conditions,  e.g.  in  continuing  to  add  numbers,  many  of  these 
patients  seem  to  tire  less  than  the  normal,  apparently  because  they  do  not 
concentrate. 

^°  The  numerous  "war  epilepsies"  do  not  confirm  these  peace  epilepsies. 
However,  on  the  one  hand,  the  time  since  the  war  is  still  somewhat  short ;  on 
the  other  hand,  the  various  brain  attacks  which  do  not  belong  to  our  concept 
of  epilepsy  are  here  included — for  the  present,  because  it  is  not  quite  possible 
to  differentiate  them,  as  the  different  kinds  of  attacks  frequently  change  from 
case  to  case  and  even  in  the  same  patient  (comp.  e.g.  Jacksonian  Epilep.  p.  342). 
Cf.  also  Forster  on  later  clinical  experiences  with  bullet  injuries  of  the  brain 
in  the  Handbuch  der  arztlichen  Erfahrung  im  Weltkrieg,  Barth,  Leipzig,  1922, 
IV,  p.  198. 

"  Trauma  und  Psychose.    Springer,  Berlin,  1915. 


242  TEXTBOOK  OF  PSYCHIATRY 

effected  by  a  removal  of  a  bone  splinter  irritating  the  brain.  Bromide 
is  sometimes  effective  against  irritability.  It  is  still  more  important 
to  be  extremely  considerate  of  the  patient  and  to  avoid  every  irritating 
circumstance.  Headache  and  similar  symptoms  frequently  only  be- 
come worse  through  treatment,  while  ignoring  it  may  make  the  con- 
dition more  bearable.  In  addition  a  suitable  selection  and  education 
of  those  persons  who  are  wont  to  come  in  contact  with  the  patient  is 
necessary.  It  is  taken  for  granted  that  the  patient  is  trained  and 
practiced  in  a  line  of  work  carefully  adapted  to  his  abilities. 

n.    INSANITY  IN  BRAIN  DISEASES 

These  psychoses  also  have  little  significance  for  psychiatry.  The 
thing  that  is  essential  from  a  practical  viewpoint  is  usually  the  basic 
disease;  but  the  psychosis  must  not  be  overlooked  because  of  the  pos- 
sibility of  its  being  mistaken  for  other  mental  diseases  and  neuroses. 
Diffuse  nutritional  disturbances  of  the  cortex  in  every  case  result  in 
the  organic  syndrome. 

In  connection  with  the  psychical  disturbances4a~th£Ljy^rious  forms 
of  meningitis,  Kraepelin  discusses  the  insanity  in  cases  of  brain  tumors. 
Here  too  the  most  different  disturbances  have  been  described,  and 
the  connections  between  the  tumor  and  the  psychosis  are  not  often 
clear.  Large  tumors  may  remain  with  hardly  any  psychic  symptoms 
or  at  any  rate  may  run  a  course  without  any  severe  manifestations. 
Brain  pressure  retards  all  reactions,  but  need  not  disturb  them  in  any 
other  way.  I  have  seen  a  case  in  which  it  might  take  five  minutes 
before  the  patient  answered  a  simple  question;  but  the  answers  were 
appropriate.  Of  theoretic  interest,  even  though  still  incomprehensible, 
is  the  frequent  occurrence  here  of  the  "facetiousness,"  which  perhaps 
appears  as  a  local  symptom  of  the  base  of  the  frontal  lobe.  It  is 
interesting  also  that,  according  to  Schuster,  tumors  of  the  corpus 
collosum  are  regularly  connected  with  psychic  disturbances. 

Where  pronounced  psychical  morbid  pictures  are  found  in  tumors, 
it  is  usually  a  case  of  the  organic  symptom  complex  (lability  of  the 
feelings,  Korsakoff  memory  disturbances,  etc.) — for  comprehensible 
reasons,  because  the  nutrition  of  the  brain  is  easily  disturbed  in  toto. 
Under  circumstances  still  unknown,  catatonic  symptoms  may  also  be 
connected  with  brain  diseases,  especially  with  tumors. 

The  disturbances  of  the  psyche  in  multiple  sclerosis  are  mainly 
those  of  the  organic  psychoses.  In  the  field  of  affectivity,  irritability 
is  often  in  the  foreground;  in  other  cases  it  is  euphoria,  or  the  reverse, 
depression.    In  most  cases  the  diseased  is  animated  by  psychogenic 


THE  INDIVIDUAL  MENTAL  DISEASES  243 

neurotic  symptoms;  since  these  are  amenable  to  the  right  psycho- 
therapy it  is  very  important,  and  usually  very  easy,  to  recognize  them. 
In  later  stages  delusions  and  delirious  conditions  may  also  be  seen. 
The  diagnosis  is  based  on  the  neurological  signs  of  multiple  sclerosis. 

Huntington's  chorea,  which  is  almost  always  hereditary,  is  more 
important.  I  knew  a  family  in  which  four  generations  were  so  afflicted. 
The  transmission  is  usually  of  the  same  variety.  But  not  seldom  other 
severe  cerebral  disturbances  such  as  epilepsy,  idiocy,  etc.,  are  also 
found  among  the  relatives.  The  psychic  and  motor  manifestations, 
as  a  rule  long  unrecognized,  appear  stealthily  mostly  in  the  second 
to  the  fourth  decade,  occasionally  still  later,  and  rarely  earlier.  Such 
persons  are  often  considered  inattentive  and  careless  and  are  blamed 
for  their  clumsiness,  in  the  appearance  of  which  the  motor-choreatic 
disturbances  participate  just  as  well  as  the  psychical.  The  chorea  in 
itself,  when  it  is  once  pronounced,  looks  exactly  like  Sydenham's  dis- 
ease, only  the  movements  are  mostly  less  brusque.  In  the  psychic 
sphere  one  observes  an  organic  dementia.  Often,  however,  there  is  a 
marked  indifference  to  the  disease  and  about  their  own  affairs  which 
is  generally  noticeable.  When  the  patients  are  no  longer  capable  of 
speaking  and  writing  they  usually  take  no  pains  at  all  to  make  them- 
selves otherwise  understood.  Changes  of  mood  are  not  so  rare  but  they 
probably  never  attain  the  degree  of  a  melancholia  or  a  mania. 

Death  results  in  the  course  of  a  few  decades  during  which  the  severe 
mental  affliction  either  progresses  steadily  or  shows  minor  fluctuations. 

The  brain  shows  markcc!)y  diffuse  changes  of  the  nervous  ele- 
ments, which  as  yet  have  not  been  sufiiciently  investigated  to  permit 
of  an  anatomical  diagnosis. 

Kraepelin  includes  in  here  the  amaurotic  idiocy  of  Tay  and  Sachs, 
which  affects  mainly  Jewish  children  in  their  first  year.  It  is  not  a 
form  of  idiocy  but  a  peculiar  brain  degeneration  involving  the  visual 
apparatus  including  the  retina  and  ends  in  death  in  several  months 
or  years. 

An  organic  brain  disease,  which  affects  the  cortex  relatively  little 
and  for  that  reason  lacks  the  organic  syndrome,  is  Encephalitis  leth- 
argica,  the  European  sleeping  sickness,  which  has  no  connection  what- 
ever with  the  African  sleeping  sickness.  Anatomically  it  is  a  poUencc- 
phalitis  in  which  there  is  a  round  cell  proliferation  of  the  vessels  and 
in  which  more  rarely  there  are  also  slight  hemorrhages.  Its  favorite 
location  is  around  the  Aqueduct  of  Sylvius  but  it  also  spreads  to  the 
canal  root  ganglia  and  their  surroundings  and  invariably  descends  into 
the  spinal  cord  but  it  probably  does  not  leave  any  part  of  the  gray 
matter  entirely  free.     The  physical  symptoms  are  paralysis  of  internal 


244  TEXTBOOK  OF  PSYCHIATRY 

and  external  eye  muscles,  sometimes  also  paralysis  of  the  facial  nerve, 
parasthesias  not  only  in  the  form  of  itching,  etc.,  but  also  pains  and 
burning,  paralyses  in  general,  and  mild  muscular  rigidity.  The  de- 
velopment of  the  disease  is  from  several  days  to  weeks;  fever  appears 
mostly  at  the  height  of  the  disease;  it  is  frequently  not  particularly 
high  and  may  disappear  after  a  few  weeks. 

Psychotic  symptoms  of  a  toxic  rather  than  organic  character 
appear  chiefly  in  the  initial  stage.  Thus  one  observes:  motor  restless- 
ness, which  sometimes  lends  a  choreic  character  to  the  movements. 
This  is  frequently  accompanied  by  deliria,  which  resemble  the  ordinary 
fever  psychoses,  but  because  of  their  complex  character  they  may  be 
readily  taken  as  hysterical,  especially  before  the  temperature  rises. 
In  severe  cases  they  increase  to  the  point  of  apparent  confusion.  Some- 
what later  the  clouded  state  often  assumes  the  character  of  occupation 
deliria,  which  alternate  with  the  ever-increasing  lethargic  state.  In 
milder  cases  one  sees  at  least  occupation  dreams.  Except  in  the  most 
severe  cases  the  patients  can  be  roused  from  their  sleep  and,  after  the 
disappearance  of  the  initial  deliria,  evince  their  meataJr-dearness,  even 
though  strikingly  uninterested  in  their  own  condition  as  well  as  in  the 
environment.  Left  to  themselves  at  the  height  of  the  disease  they 
invariably  go  to  sleep  aga4n. —The^yperkinetic  deliria  of  the  begin- 
ning are  easily  mistaken  for  catatonic  especially  because,  in  spite  of 
existing  affects,  the  facial  expression  regularly  has  something  rather 
stiff  about  it,  and  because  the  torpor  may  assume  a  real  cataleptic 
appearance.  The  occupation  deliria  may  occasion  its  being  mistaken 
for  delirium  tremens.  The  disease  often  results  in  death  in  the  early 
weeks,  in  many  other  cases  later,  even  after  more  than  two  years. 
About  two  thirds  recover  almost  entirely  in  the  course  of  a  greater 
number  of  weeks  or  months.  But  the  rigidity  of  the  pupils  is  often 
said  to  remain  permanently.  The  differential  diagnosis  is  based 
mainly  on  the  proof  of  the  following  encephalitic  symptoms:  paras- 
thesias, hyperkinesis  v/ith  chorea-like  movements  and  above  all  dis- 
turbances of  the  eye  muscle  and  eventually  of  the  optic  nerve;  also 
then  the  mania  for  sleep  with  the  possibility  of  being  aroused  to  an 
intellectually  clear  condition. 

What  excites  the  disease  and  the  manner  of  infection  are  unknown; 
the  treatment  is  symptomatic. 

in.    SYPHILITIC  PSYCHOSES 

Among  the  infectious  diseases  of  the  brain  and  its  meninges  syphilis 
is  the  most  important.     To  be  sure  even  without  the  confirmation  of 


THE  INDIVIDUAL  MENTAL  DISEASES  245 

a  luetic  process  in  the  central  organs  there  are  already  disturhanccH 
at  the  beginning  of  the  secondary  stages  of  lues,  which  are  designated 
as  "neurasthenic."  The  latter  are  due  in  part  to  the  psychic  effects 
of  the  infection,  which  nowadays  is  no  longer  taken  so  light  heartedly, 
and  in  part  probably  to  the  direct  weakening  or  poisoning  influence 
of  the  virus,  which  to  be  sure  we  cannot  as  yet  define  more  exactly. 
Manifold  signs  of  milder  disturbances  of  the  nervous  system,  .such 
as  dizziness,  headache,  diminished  pupillary  reaction  to  light,  an  in- 
crease in  the  cells  and  albumin  in  the  spinal  fluid,  which  are  frequently 
a  result  of  an  antiluetic  treatment,  lead  to  the  supposition  that  as  a 
third  factor  some  unknown  early  alteration  of  the  brain  or  of  the 
meninges  can  produce  or  condition  symptoms  resembling  those  of 
neurasthenia. 

Sometimes  the  thought  of  being  infected  and  the  fear  of  the  conse- 
quences of  lues  form  the  conspicuous  part  of  the  picture.  There 
develops  a  hypochondriacal  neurasthenia,  altogether  or  mainly  psycho- 
genetic,  with  an  eager  searching  for  morbid  symptoms  that  might  be 
ascribed  to  syphilis.  According  to  some,  hysterical  pictures  are  also 
said  to  be  produced  by  the  infection. 

In  other  cases,  according  to  Kraeyelin,  one  deals  with  a  general 
nervous  uneasiness,  increased  difficulty  in  thinking,  irritability,  dis- 
turbance of  sleep,  pressure  in  the  head,  vague  and  alternating  feelings 
and  pains,  later  on  anxiety  feelings,  pronounced  depressions,  dizziness, 
clouding,  difficulty  in  finding  words,  transitory  paralyses,  disturbances 
of  perception,  nausea,  and  a  rise  in  temperature.  The  latter  group 
of  manifestations  might  perhaps  be  ascribed  to  the  third  cause,  or  to 
some  direct  anatomical  or  chemical  disturbance  in  the  cranial  content. 

For  a  second  group  of  syphilitic  psychoses  which  are  about  equally 
frequent  in  men  and  women  we  have  an  anatomical  basis ;  among  those 
one  observes  gummata,  slowly  progressing  meningitis,  and  luetic  vascu- 
lar diseases.  In  most  cases  one  of  these  processes  predominates,  but 
the  disturbance  is  rarely  limited  entirely  to  one  of  them.  The  vascular 
alteration  is  most  often  found  alone  but  it  frequently  accompanies 
meningitis  and  both  together  are  often  found  in  an  affection  which  is 
primarily  gummatous.  The  combinations  and  the  changing  intensity 
and  location  of  the  processes  produce  a  great  variety  of  the  clinical 
pictures,  but  the  anatomical  findings  are  as  yet  only  roughly  paralleled 
with  the  clinical. 

The  Gummata  in  themselves  naturally  produce  the  identical  symp- 
toms as  other  brain  tumors  of  equally  rapid  growth  and  similar  locali- 
zation. Luetic  meningitis  is  mostly  localized  at  the  base,  especially 
in  the  region  where  the  various  optic  nerves  have  their  exit,  it  moves 


246  '  TEXTBOOK  OF  PSYCHIATRY 

rarely;  also  affects  the  convexity  and  then  usually  to  a  lesser  extent. 
The  variety  of  symptoms  caused  by  meningitis  naturally  depends  on 
the  increase  of  the  pressure  and  the  luetic  process,  or  on  whether  the 
disturbances  of  nutrition  extend  to  the  cortex  or  not.  The  diseased  pia 
is  usually  thickened,  clouded,  infiltrated  with  round  cells,  and  shows  an 
increase  in  connective  tissue. 

The  vascular  changes  in  themselves  produce  symptoms  similar  to 
the  non-luetic  arterioscleroses.  They  can  affect  more  extensively 
either  the  large  or  the  small  vessels.  The  syphilitic  vascular  disease 
shows  itself  in  the  larger  arteries  in  an  exuberance  of  the  cells  of  the 
intima  and  adventitia,  in  the  former  to  the  extent  of  occluding  the 
lumen.  The  elastica  becomes  split  apart.  The  process  has  a  certain 
tendency  towards  regeneration,  but  when  the  arteries  of  the  brain  are 
involved,  the  region  they  supply  is  usually  permanently  injured  in 
the  way  of  a  simple  gradual  destruction  of  the  nervous  elements  with 
an  infiltration  of  the  glia  to  the  extent  of  softenings  and  hemorrhages. 
The  process  is  most  marked  in  the  pia  and  seems  to  extend  from  it 
to  the  cortex. 

In  contradistinction  to  paresis  one  notes  here  a  massive  infiltra- 
tion of  the  entire  vessel  with  round  cells,  among  which  the  plasma 
cells  constitute  a  small  minority  or  are  absent,  while  in  paresis  the 
marked  infiltration  of  the  vessels  with  plasma  cells  is  particularly 
characteristic,  and  the  extensive  exuberance  of  the  intima  is  foreign 
to  this  disease.  What  is  also  characteristic  is  the  more  circumscribed 
dissemination  in  contradistinction  to  the  diffuse  disturbances  of  paresis. 

The  luetic  arteritis  of  the  smaller  vessel  often  consists  in  an  en- 
largement  and  proliferation  of  the  cells  in  the  adventitia  and  intima 
but  without  an  infiltration  of  round  cells.  Side  by  side  with  the  de- 
structive processes  one  also  finds  newly  formed  vessels  in  the  pia  and 
in  the  brain. 

The  brain  substance  is  naturally  injured  in  the  most  varied  ways 
both  qualitatively  and  quantitatively  by  the  alteration  of  the  vessels 
and  the  meninges. 

The  organic-nervous  symptoms  can  assume  pretty  nearly  all  forms 
that  are  produced  by  the  contents  of  the  cranium  and  the  spinal  canal. 
The  most  frequent  symptoms  encountered  are  reflex  disturbances  of 
the  pupils,  pressure  symptoms  with  clouding  of  sensorium,  desire  for 
sleep,  etc.,  and  apoplectiform  and  epileptiform  attacks  as  well  as 
attacks  showing  a  Jacksonian  character.  The  psychic  symptoms  are 
those  of  the  organic  psychoses.  The  specific  peculiarities  are  similar 
to  those  of  arteriosclerotic  insanity — for  the  self-evident  reason  that 
in  both  diseases  the  cortex  needs  not  be  affected  in  toto.    The  per- 


THE  INDIVIDUAL  MENTAL  DISEASES  247 

sonality  is  retained  for  a  long  timc.'^  The  patients  maintain  tiieir 
outward  demeanor  and  take  part  in  external  events.  Judgment  is  not 
so  much  disturbed;  thus  a  far-reaching  insight  into  the  disease  exists, 
in  quiet  times  even  considerable  clearness.  As  in  arteriosclerotic  in- 
sanity, here,  too,  the  psychic  symptoms,  both  as  to  time  and  number, 
are  lacunary:  many  good  individual  functions  cause  surprise  when 
found  where  others  have  been  lost;  moody  fluctuations  can  appear 
temporarily,  regardless  of  the  general  course  toward  improvement  or 
aggravation. 

After  all  this,  no  sharply  distinguishable  morbid  pictures  can  be 
expected.  It  also  happens  that  a  genuine  brain  syphilis  can  be  fol- 
lowed later  by  a  real  paresis.  Kraepelin  makes  the  following  distinc- 
tions: Forms  with  brain  pressure,  mostly  based  on  gummatous 
growths,  clinically  not  essentially  differentiated  from  diseases  resulting 
from  other  brain  tumors,  and  the  syphilitic  pseudoparesis  (correspond- 
ing approximately  to  the  post  syphilitic  dementia  of  Binsiuanger) . 

In  the  latter  it  is  most  frequently  a  case  of  a  morbid  picture  very 
similar  to  the  sim-ple  demented  form  of  paresis ;  in  the  physical  spheres 
besides  the  rigidity  of  the  pupils  to  light,  the  frequency  of  irregular 
paralyses  of  the  ocular  muscles,  and  disturbances  of  vision  are  the 
most  important  to  be  mentioned.  Disturbances  of  speech  and  writing 
may  be  present  but  they  then  are  of  a  different  type  from  that  of 
paresis. 

Much  rarer  is  the  delirious  confusion  of  Marcus  which  is  to  be 
classed  with  syphilitic  pseudoparesis.  It  manifests  itself  in  rather 
sudden  organic  deliria  with  symptoms  of  insomnia,  confusion,  anxiety, 
mistaking  the  environment,  hallucinations  of  hearing  and  sight,  mostly 
of  a  terrifying  content,  active  excitement,  and  acts  of  violence  against 
one's  own  person  and  others.  Besides  these  one  also  finds  organic 
nervous  symptoms. 

Other  forms  resemble  expansive  paresis.  The  prominent  feature 
of  the  fourth  group  is  an  organic  memory  disturbance  (''Korsakoff''). 

Syphilitic  pseudoparesis  takes  an  entirely  irregular  course;  it  can 
be  stationary  for  years.  The  outcome  in  all  cases,  when  no  anti- 
luetic  treatment  intervenes  or  wdien  this  is  not  effective,  is  an  organic 
dementia  combined  with  paralysis.  The  patients  die  of  intercurrent 
diseases,  or  from  weakness,  or  cerebral  attacks,  or  marasmic  pneu- 
monias, etc. 

The  differential  diagnosis  between  pseudoparesis  and  paresis  can- 
not be  made  at  once  in  individual  cases  with  absolute  certainty.  Im- 
provement in  the  course  of  antiluetic  treatment  does  not  exclude  the 

"Cf.  pp.  139-282. 


248  TEXTBOOK  OF  PSYCHIATRY 

element  of  coincidence.  The  probability  favoring  cerebral  syphilis  is 
the  lighter  intensity  and  extent  of  the  psychical  disturbances.  It 
may  also  be  worth  noting  that  in  paresis  milder  psychic  symptoms 
of  "the  neurasthenic"  type  have  in  most  cases  preceded  the  physical 
symptoms,  while  here  both  groups  usually  appear  together. 

According  to  Plant  the  following  should  be  especially  considered: 
Wassermann  in  the  blood  proves  lues;  its  absence  permits  the  exclu- 
sion of  the  possibility  of  cerebral  lues  with  a  probability  of  80%.  A 
pronounced  pleocytosis  of  the  spinal  fluid  in  the  advanced  stage  of 
lues  (not  in  the  initial  stage)  proves  an  organic  (meningitic)  process 
in  the  central  nervous  system;  the  same  holds  in  Nonne's  Phase  I. 
Wassermann  in  the  spinal  fluid  proves  the  luetic  affection  of  the  central 
nervous  system;  contrasted  with  the  invariably  strong  reaction  in 
paresis  (already  plain  in  0.2  ccm.  of  the  liquor)  it  is  here  weak;  the 
fluid  must  be  tested  up  to  1.0  ccm.  Lues  cerebri  may  be  excluded  with 
great  probability  when  there  is  no  Wassermann  in  tested  fluid,  an 
absence  of  Wassermann  in  the  blood,  an  absence  of  pleocytosis,  and, 
with  least  certainty,  when  there  is  a  failure  of  the  globulin  reaction. 

Apoplectic  cerebral  lues  is  supposed  to  be  the  commonest  of  the 
syphilitic  psychoses.  It  presents  about  the  same  pictures  as  the  com- 
mon post  apoplectic  dementia,  but  it  appears  most  often  at  an  earlier 
time  of  life,  shows  a  greater  desultoriness  and  regenerative  possi- 
bilities of  the  symptoms,  and  then  again  as  a  sign  of  brain  lues  it 
shows  frequent  paralysis  of  the  eye  muscles  as  well  as  pupillary 
disturbances. 

Furthermore  there  is  a  luetic  epilepsy  which  differs  from  the  other 
forms  by  the  existence  of  lues,  its  appearance  late  in  life,  occasional 
(not  invariable)  cure  through  antisyphilitic  treatment,  and  finally 
by  disturbances  of  the  eye  muscles. 

An  entirely  divergent  form  without  plain  psychic  organic  symptoms 
has  been  described  in  detail  chiefly  by  Plaut,  as  hallucinosis  of 
syphilitics,  but  he  did  not  establish  with  entire  certainty  the  concep- 
tion of  a  particular  disease.  It  is  a  question  of  cases  which  as  yet  are 
not  to  be  differentiated  clinically  from  mild  paranoid  types  with 
senseless  delusions,  voices,  very  rarely  other  hallucinations.  Halluci- 
nations referring  to  the  body  probably  also  occur;  the  patients  some- 
times feel  as  if  they  were  hypnotized.  However,  pronounced  specific 
schizophrenic  symptoms,  especially  actual  dementia,  are  absent.  De- 
pressions with  ideas  of  sin  and,  more  rarely,  exaltation  of  a  minor 
degree,  but  still  with  grandiose  ideas,  are  also  met.  Usually  there  is 
a  certain  feeling  of  sickness.  The  course  is  similar  to  many  cases  of 
schizophrenic  paranoid  types  and  shows  irregular  fluctuations  up  to 


THE  INDIVIDUAL  MENTAL  DISEASES  249 

hallucinatory  excitations,  which,  however,  remain  without  disorienta- 
tion. Cures  do  not  seem  to  occur  in  spite  of  antisyphihtic  treatment. 
Sometimes  one  also  notes  paralytic  manifestations,  pupillary  dis- 
turbances, bladder  weakness,  disturbances  of  speech  and  writing,  dizzi- 
ness and  other  cerebral  attacks.  The  disease  usually  breaks  out  more 
than  ten  years  after  the  infection. 

Plant  also  described  similar  acute  cases  with  symptoms  of  anxious 
excitation,  with  voices  and  delusions  of  persecution  without  disorienta- 
tion, which  lasted  from  18  days  to  10  months  and  usually  recovered. 
The  most  important  syphilitic  affection  of  the  central  nervous 
system  is  Dementia  paralytica.  Contrasted  with  the  other  luetic  dis- 
eases it  has  some  peculiarities  in  common  with  tabes  and  is  not  seldom 
associated  with  this  disease  as  taboparesis.  But  besides  this  there  are 
"Tabes  psychoses"  which  neither  clinically  nor  anatomically  belong 
to  paresis.  They  mostly  show  mild  indications  of  organic  symptoms, 
especially  lability,  but  also  disturbances  of  memory,  attention,  etc. 
In  all  other  respects  they  take  very  different  forms.  Following  Krae- 
pelin  affective  and  paranoid  forms  are  mostly  differentiated,  of  which 
the  latter  are  the  more  frequent. 

The  affective  pictures  manifest  themselves  in  persistent  moods,  in 
the  form  of  depression,,  irritability,  or  abnormal  euphoria.  The 
paranoid  jorms  develop  vague  delusions,  usually  of  persecution,  inter- 
mingled at  times  with  delusions  of  grandeur;  they  also  have  hallucina- 
tions of  hearing  and  occasionally  of  sight,  more  rarely  of  smell  and 
taste  and  of  body  sensations.^^ 

Even  in  the  chronic  course,  these  conditions  show  a  rather  marked 
fluctuation;  on  the  other  hand  cases  are  not  rare  in  which  the  disease 
manifests  itself  only  in  acute  shifts  of  such  hallucinations  and  delu- 
sions mostly  with  anxious  excitements  extending  to  the  point  of 
delirium.  Between  these  forms  there  are  all  combinations  and  transi- 
tions, i.e.  cases  in  which  the  delusions  continue  more  or  less  in  the 
clear  state  and  now  and  then  one  also  observes  deliria.  In  clear  mental 
states  all  these  patients  are  usually  allopsychically  oriented. 

The  much  more  frequent  occurrence  of  disturbances  of  the  visual 
nerves  in  tabes  with  psychoses  than  in  mere  symptoms  of  the  spinal 
cord  makes  it  probable  that  the  tabes  psychoses  also  are  based  on  a 
variety  of  cerebral  lues. 

Hereditary  syphilis  also  generates  numerous  brain  diseases,  which 
are  associated  with  psychic  symptoms,  they  range  from  simple  nervous- 
ness up  to  idiocy,  epilepsy,  infantile  paralysis,  and  other  progressive 
forms  of  dementia  which  have  not  been  properly  described  as  yet. 
"  Cf.  pp.  64-65. 


250  TEXTBOOK  OF  PSYCHIATRY 

According  to  Kraepelin  a  part  of  the  luetic  idiocies  already  origi- 
nated within  the  uterus,  chiefly  through  meningo-encephalitis;  others 
develop  later,  some  suddenly,  others  gradually;  later  they  may  again 
become  stationary.  Local  disturbances  of  the  brain  texture,  e.g. 
through  arterial  occlusion,  naturally  leave  pictures  similar  to  those 
of  acute  encephalitis.  According  to  some  about  10%  of  idiocies 
are  conditioned  by  syphilis.  In  some,  besides  severe  or  very  slight 
intellectual  disturbances,  one  finds  chiefly  anomalies  of  character, 
vehemence,  maliciousness,  cruelty,  and  uneducability  in  general. 
Under  certain  circumstances  paranoid  pictures  also  appear.  In  all 
these  forms  the  entire  constitution  is  mostly  impaired;  the  children 
develop  late,  remain  weak,  small,  or  deformed.  The  luetic  cerebral 
symptoms  may  appear  at  any  time,  but  most  frequently  in  the  first 
years.  But  infantile  paresis  may  first  begin  in  the  second  decade;  in 
very  rare  cases  the  outbreak  is  said  to  have  been  delayed  to  the  fourth 
or  fifth  decade. 

The  diagnosis  of  paresis  in  children  rests  on  the  same  principles 
as  in  adults.  The  other  hereditary  syphilitic  forms  are  first  proven 
as  definitely  syphilitic  by  the  success  of  therapy  or  by  the  anatomical 
examination.  At  all  events  the  specific  origin  is  indicated  with  great 
probability  by  the  demonstration  of  syphilis,  such  as  direct  luetic 
manifestations,  positive  Wassermann,  Hutchinson's  triad,  namely, 
semicircular  lower  edges  of  the  middle  upper  incisors,  keratitis 
parenchymatosa,  and  sudden  deafness  in  childhood,  further  by  the  eye 
symptoms  and  by  the  fluctuating  progressive  course. 

IV.     DEMENTIA  PARALYTICA 

Dementia  paralytica,  which  is  commonly  incorrectly  called  soften- 
ing of  the  brain  and  in  science  briefly,  paresis,  is  a  peculiar  syphilitic 
brain  disease  with  the  general  symptoms  of  the  organic  psychoses  and 
peculiar  physical  manifestations.  It  mostty  runs  a  course  of  a  few 
years  and  ends  in  death. 

Besides  the  above  mentioned  ^*  psychical  peculiarities  which  differ- 
entiate paresis  from  the  other  organic  psychoses,  there  are  still  others, 
but  as  yet  it  has  not  been  possible  to  isolate  them  clearly,  and  still  less 
to  formulate  them.  ^ 

On  the  other  hand  the  physical  symptoms  of  paresis  are  plain 
specific  signs.  Just  as  in  tabes  we  find  reflex  rigidity  of  the  pupils 
(Arg>'ll-Robertson) ;  that  is,  the  pupils  react  to  light  slowly  or  slug- 
gishly or  not  at  all,  while  reaction  to  accommodation  is  usually  longer 
or  better  preserved.  The  pupils  are  frequently  unequal,  abnormally 
"*  Cf .  pp.  235-236. 


THE  INDIVIDUAL  MENTAL  DISEASES 


251 


dilated  or  abnormally  contracted,  and  not  seldom  changed  in  form. 
Psychical  pupillary  reaction  (to  pain,  mental  exertion)  is  also  im- 
paired, but  not  to  the  extent  that  these  disturbances  would  show  a 
proportionate  relation  to  the  reflex  rigidity  of  the  pupil  or  to  the  stage 
of  the  disease. 

The  remaining  reflexes  have  nothing  characteristic  about  them;  the 
tendon  reflexes  in  simple  paresis  are  naturally  exaggerated  because 
their  control  through  the  cere- 
brum is  diminished;  when  com- 
plicated with  tabes,  that  is, 
when  there  is  an  interruption 
of  the  peripheral  spinal  reflex 
arc,  they  are  absent  at  least  in 
the  lower  extremities. 

The  coordination  of  muscu- 
lar action  suffers  in  a  striking 
manner  which  is  most  pro- 
nounced in  the  delicate  adjust- 
ments of  the  movements  of 
speech.  Individual  sounds  are 
badly  formed,  successive  sounds 
are  "run  together,"  the  patient 
prolongs  the  semi  -  vowels, 
sounds  and  syllables  are  omit- 
ted, repeated,  or  misplaced 
(stuttering  of  syllables),  and 
occasionally  the  sound  compo- 
nents of  a  word  are  changed.^^ 
The  psychic  disturbances  are 
naturally  also  present,  since 
inattention  and  weakness  of 
impressibility  or  amnestic  diffi- 
culties, make  repetition  as  well  as  spontaneous  speech  more  difiicult. 
Especially  in  the  later  stages,  the  voice  easily  becomes  trembling, 
monotonous,  and  towards  the  last  speech  is  usually  slow,  babbling, 
and  hardly  comprehensible. 

In  many  cases  the  tone  of  the  mimetic  muscles  decreases,  the  naso- 
labial folds  seem  wiped  out  (often  more  so  on  one  side),  the  finer 

"Ziehen  speaks  of  "hesitating  speech."  It  is,  of  course,  correct  to  say  that 
paretics  speak  slowly  as  soon  as  coordination  becomes  seriously  difficult ;  but 
the  term  should  be  limited  to  the  entirely  different  epileptic  speech  disturbance 
to  which  it  is  better  suited. 


Fig.  1. — The  typical  flabby  paretic  ex- 
pression. It  looks  as  if  the  mimetic 
modelling  had  been  erased  by  excessive 
retouching,  while  the  eyes  betra\'  an  af- 
fective life.  If  the  ej'es  are  covered,  the 
face  looks  like  that  of  a  sleeper.  Asym- 
metrical noso-labial  folds. 


252 


TEXTBOOK  OF  PSYCHIATRY 


mimetic  movements  are  lost.  As  a  result  the  face  assumes  a  flabby 
and  stupid  expression,  which  often  enables  one  to  recognize  the  paretic 
immediately.  Even  earlier  tremors  of  individual  groups  of  the  facial 
muscles  are  sometimes  seen   ("Heat  lightning"). 

The  tongue  is  often  put  out  hesitatingly  and  shows  tremors  of 
individual  muscle  groups. 

The  handwriting  is  changed  in  an  analogous  manner  to  speech. 
Aside  from  the  frequent  coarse  and  irregular  tremors  of  the  organic 
brain  affection  the  lines  do  not  go  where  they  should;  the  letters  be- 
come abnormally  large  and  long  and  unequal;  curves  are  made  with 

corners,  etc.;  pressure 
is  irregular.  The  psy- 
chical difiiculties  are 
as  follows:  omissions, 
repetitions,  inter- 
change of  letters,  syl- 
lables and  words, 
blotting,  wrong  cor- 
rections, incorrect  syn- 
tax, the  end  does  not 
fit  the  beginning  of 
the  sentence  and,  fi- 
nally, only  an  illegible 
scribbling  is  produced. 
Disturbance  of  the 
gait  usually  becomes 
plain  somewhat  later, 
unless  tabes  with  its 
characteristic  signs  of  the  psychosis  precedes.  The  foot  misses  its 
mark,  deviating  now  to  the  front,  now  to  the  rear  or  side  ways. 
Thus  the  walk  becomes  irregular,  swaying,  with  legs  spread  apart, 
and  at  the  same  time  weak,  and  in  certain  respects  spastic  (but  not 
in  the  sense  of  spastic  spinal  paralysis  with  its  difficulty  of  freeing  the 
tip  of  the  foot  from  the  ground) .  Inequality  of  the  two  sides,  "hang- 
ing" of  the  entire  body  to  the  left  or  right  is  not  rare.  In  the  last 
stages  walking  is  generally  impossible. 

Gradually  the  entire  muscular  system  attains  a  condition  of  ex- 
treme spastic  paralysis;  the  patient  becomes  entirely  helpless.  The 
involuntary  muscular  system  is  also  affected:  swallowing  becomes 
difficult  and  impossible ;  the  intestines  no  longer  advance  their  content ; 
more  frequently  incontinentia  alvi  et  urinae  exists,  the  latter  often 
together  with  paralysis  of  the  bladder. 


Fig.  2. — Paretic.  In  spite  of  a  strained  pose,  ex- 
pressed in  the  frown  and  eyes,  the  part  of  the  face 
below  the  eyes  remains  flabby. 


THE  INDIVIDUAL  MENTAL  DISEASES  253 


U^AOfi^ 


Figs.  3a  and  b. — Paresis.  Paretic  script.  Disturbance  of  coordination  is  espe- 
cially plain  in  the  M.  and  the  H.,  the  former  showing  it  by  the  intemiptions  in 
the  lines,  numerous  but  vain  efforts  to  continue  the  strokes.  This  is  particularly 
seen  in  the  letters  r  and  in  the  word  beautiful,  which  is  hardly  legible.  In  example 
(b)  one  sees  besides  some  reduplications  of  strokes  and  letters  and  a  fusion  of 
letters,  etc. 


254  TEXTBOOK  OF  PSYCHIATRY 

The  blood  in  most  cases  shows  a  positive  Wassermann,  the  liquor 
cerebro  spinalis  nearly  always.  The  latter  ^^  is  mostly  under  increased 
pressure  and  because  it  contains  globulin  it  is  clouded  by  the  addition 
of  an  equal  amount  of  saturated  solution  of  ammonium  sulphate 
(Nonne,  Phase  I) ;  it  also  contains  an  abnormal  amount  of  albumin 
(Nissl  reaction  with  the  Esbach  reagent) ,  and  shows  always  a  hyper- 
lymphocytosis,  in  which  the  presence  of  plasma-cells  especially  (and 
eventually  broken-down  cells)  is  said  to  be  important  for  the  special 
diagnosis.  The  number  of  cellular  elements  may  rise  in  paresis  to 
several  hundred  in  the  cubic  millimeter. 

The  above  mentioned  physical  symptoms  must  be  classed  with 
the  fundamental  symptoms  of  paresis,  even  though  in  very  rare  cases 
they  may  be  only  indistinctly  evidenced  throughout  the  entire  course. 
Neither  in  the  time  of  appearance  nor  in  regard  to  their  intensity 
is  there  a  definite  correlation  with  the  psychic  defects,  and  they  may 
appear  earlier  or  later  than  these.  Disturbance  of  coordination  is 
not  seldom  found  afterwards  in  earlier  specimens  of  the  patient's  hand- 
writing, and  the  pupillary  disturbances  especially  may  manifest  them- 
selves years  before  the  outbreak  but  may  be  lacking  in  a  pronounced 
psychosis. 

Among  the  accessory  physical  symptoms  the  paretic  attacks  are 
most  frequent.  They  resemble  those  of  other  severe  brain  diseases. 
Mostly,  but  not  always,  they  appear  suddenly;  consciousness  is  usually 
lost  and  then  convulsions  appear,  in  part  general,  in  part  somehow 
localized,  sometimes  also  they  are  of  the  Jacksonian  type.  There  is 
no  "striking  blindly"  as  is  so  common  in  epileptiform  attacks.  They 
may  last  for  seconds  or  for  days,  and  consciousness  often  returns  before 
the  convulsions  cease. 

Besides  these  attacks,  which  are  characteristic  of  gross  brain  lesions 
in  general,  mere  fainting  spells,  epileptiform  and  apoplectiform  attacks 
occur.  The  latter  may  leave  half  sided  or  monoplegic  paralyses, 
which  mostly  have  a  spastic  character  and  need  not  be  based  on  ascer- 
tainable anatomic  lesions,  even  when  they  no  longer  disappear,  which 
is  the  exception.  Attacks  of  fever  lasting  for  hours  or  days  may  be 
based  on  abnormal  conditions  of  the  heat  centers  or  on  a  sudden  in- 
crease of  the  spirilli. 

Aside  from  decalcification  of  the  bones  various  kinds  of  trophic 
disturbances  occur.  Decubitus  cannot  sometimes  be  avoided  in  the 
final  stage,  not  only  because  of  the  paralyses  and  uncleanliness  but 
because  of  trophic  changes.  Othaematoma  may  also  appear  without 
the  application  of  violence. 

"Comp.  pp.  238.  etc. 


THE  INDIVIDUAL  MENTAL  DLSEASES  255 

The  weight  of  the  body  is  strongly  influenced  by  the  diseaHe;  the 
euphoric  forms  are  mostly  well  nourished,  sometimes  till  death;  but 
usually  marasmus  appears  in  the  final  stage  of  the  disease.  Other 
cases  are  marasmic  from  the  beginning. 

The  appetite  is  at  times  excessive,  at  times  lacking,  as  a  rule 
fluctuating  with  the  prevalent  mood ;  exaggerated  gorging  often  exists, 
especially  in  the  demented  stage  of  the  manic  form. 

Sleep  is  very  variable;  in  all  excited  states  it  is  naturally  brief; 
in  the  quiet  stages  preceding  the  deep  dementia  it  is  mostly  normal; 
in  the  last  stage  the  nights  easily  become  restless.  Pathological  sleepi- 
ness is  much  rare. 

The  sexuaUty  is  usually  changed;  in  the  beginning  of  the  manic 
forms  the  libido  is  mostly  increased,  later  potency  disappears  first, 
then,  also,  the  desire. 

Like  tabes,  paresis  also  is  sometimes  accompanied  by  optic  atrophy 
which,  however,  may  fluctuate  strongly  in  a  striking  manner,  that  is, 
vision,  in  the  course  of  months  becomes  worse  and  better;  total  blind- 
ness is  an  exception.  Paralyses,  mostly  transient,  of  individual  eye 
muscles  are  not  so  rare  (especially  in  the  incipient  stages) ;  definite 
degenerations  of  individual  nerve  roots  may  occur. 

Sensory  symptoms  in  the  form  of  headache,  ordinary"  and  "ophthal- 
mic" migrain,  and  other  parasthesias  are  not  rare  and  are  prominent, 
especially  in  the  preparatory  stage,  where  they  are  taken  for  neuritis 
and  rheumatisms.  The  very  frequent  hypalgesia  or  analgesia  which 
mostly  affects  only  the  skin,  is  diagnostically  important. 

Among  the  psychic  accessory  symptoms  endogenous  affective 
fluctuations  of  the  manic  or  melancholic  type  dominate  the  external 
picture  so  frequently  that  they  have  been  used  as  characteristic  of 
sub-groups. 

Hallucinations  (almost  entirely  of  sight  and  hearing)  do  not  play 
a  large  part;  most  cases  run  their  course  without  them.  Only  rarely 
are  illusions  prominent  for  any  length  of  time. 

On  the  other  hand  delusions  are  frequent  and  are  mostly  connected 
with  the  emotional  shiftings.  They  are  not  nearly  so  fixed  as  in  the 
paranoid  conditions,  and  especially  in  the  manic  forms  they  change 
in  extent  and  intensity  with  the  strength  of  the  affective  fluctuations 
and  the  weakness  of  judgment;  they  also  increase  through  preoccupa- 
tion with  them.  The  patient  has  the  idea  that  he  owns  twenty  horses ; 
as  soon  as  he  has  imagined  this,  it  is  not  enough  and  he  owns  one 
hundred,  then  two  hundred,  etc.  Delusions  may  also  be  provoked  or 
modified  by  remarks:  The  patient  is  asked  whether  he  did  not  have 
a  rank  in  the  army  and  he  readily  becomes  a  general-     They  are  sense- 


256  TEXTBOOK  OF  PSYCHIATRY 

less,  partly  because  of  the  enormous  exaggeration,  partly  qualitatively: 
A  paretic  wants  to  become  rich  by  purchasing  a  house  with  a  mort- 
gage of  $70,000,  that  pays  $1600  interest;  he  wants  to  earn  a  million 
with  a  toboggan  slide:  "Admission  with  a  bottle  of  fine  wine  two 
dollars."  Another  buys  for  his  own  use  one  hundred  cases  of  maca- 
roni and  all  sorts  of  perishable  things  in  similar  quantity,  he  orders 
"a  boat  load  of  champaign." 

In  some  cases  severe  focal  symptoms  are  noticed,  indefinitely  cir- 
cumscribed paralyses  of  the  cerebral  type  {facial  nerve  inequality  espe- 
cially of  the  lower  branch  is  very  frequent) ,  aphasic  and  apractic  dis- 
turbances, etc.  In  the  later  stages  manifestations  of  irritation  as 
smacking  the  lips,  grinding  the  teeth  and  other  spasmodic,  more  or 
less  coordinated  movements  sometimes  appear. 

Especially  in  the  final  stage,  symptoms  also  occur  that  externally 
look  the  same  as  those  of  catatonia  and  cannot  as  yet  be  properly 
differentiated  from  them;  they  show  themselves  in  manifestations 
which  one  is  inclined  to  designate  as  verbigerations,  stereotypes,  and 
echopraxias. 

Course.  As  a  rule  paresis  results  in  death  within  a  few  years. 
The  few  so-called  cures,  which  are  mentioned  in  the  literature  of  the 
subject,  are  doubtful  (wrong  diagnoses?  long  remissions?).  In  rare 
exceptional  cases  a  remission  may  last  a  decade  or  even  longer  and 
even  without  a  plain  remission  a  case  may  be  drawn  out  for  many 
years.  That  is  so  rare,  however,  that  it  should  not  be  considered. 
The  galloping  form  may  result  in  death  after  an  excitement  lasting 
eight  days. 

The  onset  is  probably  always  gradual,  even  in  the  case  where  an 
acute  attack  first  makes  the  disease  manifest  to  those  around  it. 
Pupillary  disturbances  as  well  as  transformations  of  character  in  many 
cases  can  be  shown  to  have  taken  place  a  decade  before  the  actual 
outbreak  and  symptoms  like  those  of  neurasthenia  may  for  a  few  years 
exclusively  announce  the  severe  disease. 

But  when  the  paresis  is  once  noticeable,  extensive  remissions  may 
simulate  a  cure.  This  hardly  ever  occurs  in  the  simple  demented 
form. 

The  different  manifestations  may  appear  in  an  entirely  irregular 
sequence.  In  the  prodromal  stage,  i.e.  before  the  disease  is  recognized, 
pupillary  disturbances  and  those  of  writing,  and  transformations  of 
character,  are  most  frequent.  A  neurasthenic  symptom,  a  paralytic 
attack,  or  another  physical  sign  may  begin  the  action  just  as  well  as 
a  pronounced  psychic  syndrome,  e.g.  a  senseless  or  criminal  act.  For 
the  later  stages,  too,  no  rules  can  be  set  up,  except  perhaps  that  the 


THE  INDIVIDUAL  MENTAL  DISEASES  267 

excitements  in  severe  dementia  naturally  readily  assume  the  character 
of  confusion. 

As  the  most  frequent  premonitory  symptoms  should  be  mentioned 

the  pupillary  disturbances  and  in  complication  with  tabes  the  absence 
of  the  patella  reflex,  then  irritability,  anxiety,  excessive  ambitions  or, 
the  reverse,  unusual  weakness  of  will,  twilight  states  lasting  for 
minutes  or  hours,  very  similar  in  appearance  to  the  epileptic,  often 
with  some  incorrect  act,  attacks  of  dizziness,  fainting  spells,  transient 
double  vision,  temporary  failure  of  speech,  sleep  disturbances  and 
especially  the  neurasthenic  syndrome. 

The  last  stage  is  essentially  the  same  in  the  different  forms;  non- 
essential differences  are  brought  about  by  the  affectivity  (euphoric  in 
most  cases,  depressive  or  indifferent  in  others),  and  by  the  existence  or 
absence  of  erethic  conditions.  The  individual  morbid  pictures  will 
be  discussed  below. 

Death  results  in  the  uncomplicated  cases  from  marasmus  with  or 
without  pneumonia.  Paralysis  of  the  bladder  and  decubitus  give 
occasion  for  infections  of  all  sorts.  Paralysis  of  the  muscles  of  swal- 
lowing and  respiration  may  produce  pneumonia  and  choking. 
Paralytic  attacks  may  also  prove  fatal.  Many  patients  come  to  grief 
because  of  their  motor  or  psychic  deficiencies;  suicides  occur  in  the 
depressive,  more  rarely  in  the  simple  forms. 

The  duration  of  paresis  is  difficult  to  determine.  The  better  the 
anamnesis  the  further  it  can  be  dated  back,  not  so  seldom  to  a  decade 
before  the  manifest  outbreak.  From  this  period  on  the  disease  lasts, 
on  the  average,  about  three  years;  the  shortest  course  runs  in  the 
agitated  forms.  In  all  forms,  except  the  agitated,  single  cases  may 
be  protracted  over  a  very  long  period;  the  maximum  noted  so  far 
in  one  case  is  thirty-two  years. 

Grouping.    To  present  the  different  clinical  pictures  of  paresis, 

four  main  types  have  been  differentiated  into  which  most  cases  can 

be  classed.    But  there  are  continuous  transitions  from  one  form  to 

another.     The  individual  case,  however,  remains  usually,  not  unex- 

^  ceptionally,  within  the  type  of  the  form  it  has  once  assumed. 

1.  In  the  simple  demented  form,  stronger  exaltations  and  depres- 
sions, delusions,  and  confused  states  are  lacking.  On  the  other  hand 
besides  the  typical  organic  dementia  it  exhibits  as  a  rule  the  different 
physical  symptoms,  especially  attacks.  For  self-evident  reasons  it  is 
usually  recognized  rather  late.  At  first  not  much  else  is  noticed  than 
that  the  patients  very  gradually  decline  in  their  occupation — the 
simpler  this  is  the  later  it  is  seen, — then  they  become  more  and  more 
demented,  awkward,  and  weaker. 


258  TEXTBOOK  OF  PSYCHIATRY 

2.  The  manic  or  expansive  form,  also  called  the  classical  form, 
because  it  was  the  first  type  recognized,  often  becomes  manifest 
through  a  very  acute  manic  attack  with  a  feeling  of  intense  joy  and 
power,  flight  of  ideas,  enormous  impulse  to  activity  in  which  the  most 
senseless  delusions  of  grandeur  betray  the  deep  seated  disturbance 
of  intelligence.  The  patient  is  not  only  God,  but  possibly  a  super 
God,  he  possesses  trillions,  and  with  millions  of  ships  as  large  as  Lake 
Superior,  he  constantly  brings  home  diamonds  from  India,  hunts  on 
the  moon,  has  invented  a  bicycle,  with  which  in  three  minutes  one 
can  ride  over  land  and  sea  around  the  earth,  etc.  He  is  a  general, 
salutes  everybody  at  the  railway  station  and  whoever  does  not  respond 
to  the  salute  he  wants  to  have  shot.  Paretic  women  are  the  most 
beautiful  that  were  ever  on  earth,  all  human  beings  are  their  own  chil- 
dren whom  God  brings  forth  every  second  from  their  womb.  The 
imagination  does  not  always  reach  so  far,  and  in  the  later  stages  of 
dementia  the  evaluation  of  the  possession  sometimes  takes  the  place 
of  its  magnitude:  The  patient  boasts  that  every  month  he  kills  five 
or  six  pigs;  he  can  lift  a  half  a  hundred  weight;  he  tells  that  he  has 
inherited  a  dollar  or  that  he  has  a  fine  hat  at  home,  with  the  same 
satisfaction  as  if  he  owned  the  earth. 

Delusions  of  grandeur,  pressure  activity,  and  lack  of  critical  atti- 
tude are  often  expressed  in  inventions  which  are  usually  colossal  non- 
sense. At  times,  however,  something  less  stupid  may  result.  Thus 
a  man  suffering  from  paresis  invented  a  mixture  to  freshen  up  high 
hats  temporarily  and  supported  himself  with  it  for  two  years  after 
he  had  become  useless  for  other  work.  Another  speculated  on  the 
rise  of  cotton  prices  while  a  fall  was  generally  expected  and  won 
nearly  half  a  million  francs. 

3.  The  melancholic  or  depressive  form  usually  begins  less  acutely; 
the  fluctuations  also  are  rarely  so  great.  The  patients  usually  never 
come  out  of  their  depression.  The  delusions  are  just  as  senseless  but 
take  the  form  of  ideas  of  impoverishment,  of  sin,  and  especially  of 
the  hypochondriacal  and  nihilistic  types. 

4.  The  rather  rare  agitated  form  is  defined  in  various  ways.  I 
should  like  to  include  here  only  those  cases  in  which  one  sees  violent 
motor  excitements  with  confusion  and  failure  to  recognize  the  environ- 
ment, without  a  manic  condition;  in  addition  hallucinations  and 
illusions  of  hearing  and  vision  invariably  occur.  Furthermore  one 
also  finds  coarse  cerebral  irritating  manifestations  such  as  gnashing 
of  teeth,  convulsive  movements,  later  carphologia.  The  disease  thus 
runs  a  course  resembling  the  picture  of  the  old  "acute  delirium";  the 
patients  exhaust  themselves  after  a  week  or  more  and  therefore  usually 


THE  INDIVIDUAL  MENTAL  DISEASES  259 

succumb  during  the  first  attack.     In  milder  cases  the  disease  drags 
along  for  months  and  in  very  mild  cases  remissions  may  even  occur. 

Other  observers  designate  also  as  agitated  those  cases  of  manic 
paresis  which  show  marked  excitement  and  rapidly  succumb  to  ex- 
haustion, cases  which,  corresponding  with  the  virulence  of  the  morbid 
process,  show  more  confusion  and  agitation  than  mania  and  pressure 
activity.  From  the  two  forms  described  those  that  run  a  rapid  fatal 
course,  from  one  to  a  few  weeks,  are  distinguished  as  galloping  paresu. 

In  the  common  classification  one  does  not  find  euphoric  paresis 
which,  though  showing  a  persistently  exalted  mood  with  some 
grandiose  ideas,  never  reaches  to  the  height  of  a  manic  condition.  To 
be  sure,  it  may  be  regarded  as  an  intermediate  form  between  simple 
and  manic  paresis  into  both  of  which  it  extends  without  limits  but 
because  it  is  the  most  frequent  form,  at  least  with  us,  I  should  like 
to  emphasize  it  particularly. 

Of  the  related  forms  one  should  mention  the  cyclic,  in  which  manic 
and  melancholy  states  alternate  for  a  time  with  or  without  intervals 
of  an  indifferent  mood.     It  is  very  rare. 

Many  cases,  which  later  are  to  be  classed  mostly  with  the  depres- 
sive, somewhat  less  often  with  the  simple  form,  are  conspicuous  be- 
cause of  an  extended  incipient  stage,  closely  resembling  neurasthenia 
and  frequently  mistaken  for  it.  If  the  nervous  symptoms  are  perma- 
nently prominent,  it  is  sometimes  called  neurasthenic  paresis. 

A  paranoid  form  is  rarely  met  which  for  several  years  impresses 
one  as  paranoia  and  only  then  takes  the  usual  course.  The  picture 
may  also  be  complicated  by  depressive  moods  and  corresponding 
delusions, 

Tabo-paresis  is  the  designation  for  the  rather  frequent  association 
of  paresis  with  tabes;  it  is  supposed  to  be  peculiar  also  in  the  entire 
combination  of  the  paretic  symptoms,  in  so  far  as  it  runs  a  slow  course 
with  less  pronounced  real  paretic  manifestations. 

A  catatonic  variety  has  also  been  distinguished  but  it  is  still  an 
open  question  on  what  the  addition  of  catatonic  or  apparently  cata- 
tonic symptoms  is  based  (the  occurrence  of  paresis  in  a  case  of  schizo- 
phrenia or  in  a  schizophrenic  disposition?). 

Some  cases,  which  in  other  respects  are  different,  incline  to  stupor 
lasting  for  weeks  or  years.  Here  it  is  possible  occasionally,  but 
not  always,  to  prove  a  complication  with  a  previously  existing 
schizophrenia. 

Morbid  Picture  of  the  Manic  Form.  In  individual  but  rare  cases, 
occulo-motor  paralyses,  pupillary  rigidity  to  light,  diminution  of  the 
tendon  reflexes  precede  the  acute  outbreak  several  years.    The  ocular 


260  TEXTBOOK  OF  PSYCHIATRY 

paralysis  can  usually  be  cured  by  antisyphilitic  treatment;  but  the 
other  symptoms  improve  less  often.  These  cases  then  have  a  pause 
of  several  years  after  which  the  real  onset  does  not  differ  from  the 
usual  outline  that  follows. 

A  man,  mentally  and  physically  robust,  begins  now  and  then  to 
complain  of  "nervous"  symptoms;  a  little  headache  or  head  pressure 
or  fatigue,  either  general  or  locahzed,  e.g.  in  the  eyes;  his  sleep  be- 
comes irregular.  This  is  considered  natural  and  is  ascribed  to  over- 
work. Treatments  at  times  seem  to  bring  about  a  temporary  improve- 
ment, sometimes  none;  a  review  of  the  history  extending  over  longer 
periods  would  show  that  the  uncomfortable  condition  gets  rather  worse, 
and  the  ability  to  work  decreases.  Topalgias  or  any  other  pains, 
which  are  interpreted  and  treated  as  nervous  or  rheumatic,  are  some- 
times quite  prominent. 

At  the  same  time,  or  even  a  few  years  earlier  there  begins  in 
many  cases  a  very  gradual  transformation  of  character  that  is  so 
stealthy  that  it  is  usually  overlooked.  The  careful  head  of  a  family 
now  and  then  seems  selfish  or  careless  in  a  particular  act,  perhaps, 
contrary  to  his  previous  disposition,  he  engages  in  a  careless  business 
transaction  or  without  sufficient  reason  he  at  times  does  not  feel  like 
going  to  work. 

An  able  country  doctor  gives  up  his  practice ;  he  wants  to  be  a  sur- 
geon and  enters  a  clinic  as  an  assistant  but  fails  in  spite  of  other  good 
qualities  because  he  does  not  learn  to  control  asepsis  sufficiently.  Then 
he  buys  a  second  house  and  arranges  it  as  a  sanitarium  that  prospers 
for  a  few  years.  Another  physician  begins  enthusiastically  and  with 
great  success  to  carry  on  abstinence  propaganda,  but  then  leaves 
everj'thing  to  become  the  head  of  a  cooperative  private  institution 
with  a  doubtful  future.  Both  physicians  after  a  few  years  are  stricken 
with  pronounced  manic  paresis. 

Later  in  the  disease  intellectual  disturbances  become  plainer,  even 
though  in  the  incipient  stage  they  are  rarely  noticed  and  still  less  con- 
sidered morbid.  The  physician  who  took  over  the  new  institution 
once  figured  in  all  seriousness  that  he  need  only  prescribe  double  the 
length  of  stay  in  the  sanatorium  to  his  patients,  then  he  would  have 
twice  as  many  inmates,  and  this  he  did  several  years  before  the  dis- 
ease became  manifest;  later  he  was  still  capable  of  picking  up  in  a 
clinic  a  considerable  knowledge  of  psychiatry  and  of  establishing  a 
thriving  city  practice. 

Intelligent  relatives  are  first  conscious  of  the  increasing  lability  of 
the  feelings,  at  times  in  the  sense  of  irritability,  at  times  rather  in  the 
sense  of  sanguine  temperament  with  emotional  flights,  up  and  down. 


THE  INDIVIDUAL  MENTAL  DISEASES  201 

Shortly  before  the  outbreak  one  notices  trespasses  against  good  morals; 
the  patient  begins  to  cheat  at  cards  or  he  becomes  sexually  ofTcnsive 
or  commits  crimes. 

There  is  reason  to  suppose  that  such  prodromal  symptoms  arc 
not  lacking  in  any  case;  but  they  are  not  always  noticed.  In  mont 
cases  the  acute  manifestation  usually  surprises  the  family. 

Within  a  few  weeks,  often  even  within  a  few  days,  a  manic  condi- 
tion attains  its  highest  point  with  flight  of  ideas,  exalted  mood,  tireless 
pressure  activity,  and  flourishing  delusions  of  grandeur.  The  patient 
feels  capable  of  anything,  undertakes  senseless  transactions,  makes 
inventions,  becomes  engaged  to  three  women  at  the  same  time,  for 
whom  he  bought  three  identical  brooches  with  stones  made,  in  order 
to  send  them  to  all  three  on  the  same  day.  Whoever  hinders  him  is 
brutally  treated  as  an  enemy;  it  comes  to  noisy  scenes,  peace  and 
decency  are  violated,  and  then  the  patient  is  quickly  taken  to  an  insti- 
tution. Here  right  at  the  beginning  one  often  finds,  in  mild  or  pro- 
nounced form,  the  symptoms  referring  to  speech,  pupils,  and  hypalgesia 
of  the  skin.  The  absence  of  critical  faculty  usually  increases  very 
quickly,  the  patient  is  God,  the  President,  or  Pope ;  he  throws  millions 
around.  Thus  a  chemist  discovered  the  fourth  dimension:  "right — left, 
two  dimensions,  front — rear,  two  more,  equals  four,  strange  that  the 
world  had  to  wait  for  me  to  find  this  egg  of  Columbus." 

Such  patients  are  restless  day  and  night;  they  tear  up  things,  rattle, 
sing,  and  scold. 

After  a  few  months  the  manic  condition  usually  dies  down  and  gives 
way  to  a  quiet  euphoria.  The  physical  symptoms  also  may  subside, 
in  rare  cases  to  complete  disappearance.  The  patient  now  considers 
himself  cured,  he  has  a  certain  insight  concerning  his  excitement,  and 
corrects  the  worst  delusions  but  considers  the  attack  not  so  severe,  or 
as  the  self-evident  result  of  confinement,  etc.  In  some  cases,  which 
are  described  as  rareties,  he  may  for  a  few  years  regain  complete 
capacity  for  work.  Usually,  however,  he  is  more  or  less  markedly  re- 
duced, affectively  too  labile  and  uncritical,  but,  in  spite  of  this,  he 
may  be  considered  healthy  by  his  relatives.  And  herein  lies  a  great 
danger.  If  he  has  not  ruined  his  fortune  at  the  beginning  of  the  attack, 
he  is  now  in  danger  of  doing  so.  IMoreover  it  is  sometimes  noticeable 
that  he  does  not  observe  the  rules  of  social  intercourse;  he  may  go 
to  sleep  at  a  gathering  and  pass  the  matter  by  with  indifference. 

The  remission  usually  lasts  a  greater  number  of  months ;  then  there 
sometimes  follows  a  manic  condition  similar  to  the  first,  more  fre- 
quently a  milder  excitement  with  increased  dementia.  This  game  may 
be  repeated  several  times.     A  number  of  delusions  are  retained  and 


262 


TEXTBOOK  OF  PSYCHIATRY 


•jjvv.    '..'..■■■              i-^.'    .      ■          ''•■"■•.'■  ^•■•■■.•••.  •^•j,;*;:    l-'-r.-;''' 
Si;.-:- •->.;•'•...••.;.■  -.S  v  ^    ./*  ;V..--.'     •' .-   -M  ,./ 


Fig.  4.— Cortex  in  paresis.  Cells  stained.  Disturbance  of  the  layers.  Thicken- 
ing of  the  pia.  Enlargement  of  many  vessels.  Infiltration  of  small  cells  into 
the  pia  and  walls  of  blood  vessels. 


THE  INDIVIDUAL  MENTAL  DISEASES  203 

produced  at  every  opportunity,  even  during  the  remission:  "Tomorrow 
I  dine  witli  the  President."  In  many  cases  such  ideas  are  produced 
in  ever  increasing  numbers  and  in  even  more  senseless  quality,  and 
are  mingled  with  the  products  of  confabulation.  Educated  patients 
endeavor  at  the  same  time  to  retain  their  bearing;  but  they  do  not 
succeed  in  every  respect;  they  easily  become  filthy,  and  lose  their 
self-control.  With  or  without  external  causes  excitements  arise;  if 
the  physician,  as  is  often  the  case,  must  refuse  the  patient  some- 
thing, the  latter  promises  to  have  his  head  cut  off;  he  summons  a 
regiment,  a  billion  soldiers,  who  will  shoot  down  the  physician  and 
the  institution  and  the  entire  city.  But  very  soon  he  is  friendly  and 
happy  again.  Excitements  from  within  usually  last  longer,  sometimes 
weeks  or  months. 

In  the  meantime  paretic  attacks  may  occur  from  which  the  patient 
mostly  recovers  very  well. 

As  times  goes  on,  the  weakness  of  judgment  and  lack  of  critical 
faculty  becomes  more  marked,  new  material  is  less  and  less  produced ; 
the  patient  still  repeats  in  a  stereotype  fashion  his  old  ideas ;  he  indus- 
triously gathers  all  sorts  of  refuse,  and  becomes  unclear  in  all  respects. 
He  becomes  entirely  incapable  of  comprehending  the  environment; 
he  does  not  know  where  he  is,  and  what  happens  about  him.  Even 
without  aphasic  disturbances  it  ultimately  becomes  impossible  for 
him  to  comprehend  even  the  simplest  requests,  let  alone  comply  with 
them.  The  physical  symptoms  take  the  upper  hand,  his  speech  be- 
comes a  hardly  comprehensible  babble,  his  helplessness  in  all  respects 
becomes  worse,  the  patient  has  to  be  kept  in  bed  more  and  more,  he 
cannot  attend  to  any  of  his  needs  himself,  he  becomes  unclean,  partly 
from  psychical  indifference,  in  part  from  paralysis  of  the  sphincter 
muscles  or  from  incontinentia  paradoxa.  He  chokes  easily,  or  in  great 
gluttony  he  shoves  in  so  much  food  that  the  mouth  cavity  and  throat 
are  completely  stuffed. 

The  state  of  nutrition  is  mostly  noticeably  good  for  a  long  time, 
often  until  death.  In  some  cases  marasmus  occurs  during  the  final 
stage;  and  in  rare  cases  it  is  followed  by  marked  obesity.  The  end 
finally  results  from  an  attack,  a  simple  cortical  paralysis,  a  terminal 
pneumonia,  decubitus  with  infection,  or  a  fracture  resulting  from 
the  osteoporotic  bones;  in  the  majority  of  cases  death  comes  without 
the  patient  being  conscious  of  his  misery  and  without  the  disappear- 
ance of  his  euphoria. 

Morbid  Picture  of  the  Depressive  Form.  Many  of  these  patient-s, 
simply  because  they  are  timid,  exhibit  the  "nervous  symptoms"  at  an 
early  stage  and  to  a  marked  degree.     Such  patients  are  frequently 


264 


TEXTBOOK  OF  PSYCHIATRY 


THE  INDIVIDUAL  MENTAL  DISEASES  265 

treated  for  several  years  as  neurasthenics.  Ultimately,  however,  one 
notices  the  decline  of  the  ordinary  psychic  functions,  or  the  paretic 
physical  symptoms.  The  depression  becomes  worse,  coming  either 
in  attacks  or  progressing  gradually;  it  is  usually  connected  with 
anxiety.  An  attempt  at  suicide  often  brings  the  patient  into  the  in- 
stitution. There  he  is  terribly  unhappy,  he  feels  that  he  has  com- 
mitted every  sin,  he  is  punished  in  an  appalling  manner  here  on  earth 
as  well  as  in  the  hereafter,  the  world  has  come  to  an  end  or  has  never 
existed,  his  entrails  have  been  consumed,  and  his  limbs  are  wooden; 
"I  have  large  legs,  I  no  longer  have  any  legs,  I  do  not  exist."    Some 


Fig.  6. — Paresis.    Gliosis  at  the  cortical  edge  and  around  a  smaller  blood  vessel. 

bear  their  fate  with  a  certain  outward  calm  and  remain  in  bed,  others 
run  about,  cling  to  everything,  push  away,  scream  incessantly,  until 
death  relieves  them. 

The  picture  of  simple  paresis  is  more  monotonous.  With  or  with- 
out nervous  symptoms,  often  slowly  in  the  course  of  several  years, 
often  more  rapidly  in  a  few  w^eeks,  the  patient  fails  in  his  work  and 
in  his  social  conduct.  He  becomes  flighty  and  careless,  forgets  to  pay 
his  club  bills  or  gets  served  without  having  any  money.  He  becomes 
selfish,  dissatisfied  with  his  clothes,  although  he  neglects  himself, 
scolds  if  everything  is  not  according  to  his  wishes,  buys  four  umbrellas 
at  once  without  knowing  why,  or  cannot  find  his  way  in  the  city.    The 


266  TEXTBOOK  OF  PSYCHIATRY 

cook  puts  too  much  salt  into  the  food  or  none  at  all,  or  pours  petroleum 
on  the  salad  and  puts  sugar  into  the  soup;  later  she  throws  into  one 
pan  "everything  that  is  in  the  larder."  The  wife  knits  stockings  of 
senseless  shape  and  size.  A  woman  patient  brought  into  the  institu- 
tion five  pounds  of  cigar  butts  in  her  coat  pockets.  Aside  from  this, 
the  mental  and  physical  basic  symptoms  gradually  become  plain;  the 
latter  often  follow  paralytic  attacks  which  seem  to  be  here  particularly 
frequent.    The  patient  mistakes  places,  calls  a  seal  a  sleigh  ride,  etc. 


Fig.  7. — Paresis:  Infiltration  of  round  cells  into  a  cortical  blood  vessel. 

Mild  excitations  are  sometimes  observed.  The  patients  change 
their  vocation  several  times,  they  are  little  concerned  with  time  and 
custom,  e.g.  they  get  up  in  the  middle  of  the  night  to  take  senseless 
walks.     Frequently  they  indulge  in  drinking  and  sexual  excesses. 

The  simple  demented  paretics  usually  come  to  the  institution  in 
a  seriously  reduced  state.  As  there  is  nothing  acute  that  can  become 
regenerated,  extensive  remissions  are  very  rare  in  these  cases.  Usually 
they  are  entirely  lacking  and  the  mental  and  physical  decline  begins 
pretty  quickly. 

The  euphoric  form  most  closely  resembles  the  manic,  only  the 
fluctuations  in  a  good  and  a  bad  direction  are  lacking,  or  they -are 
slighter,  and  especially  never  attain  the  height  of  a  manic  state.    The 


THE  INDIVIDUAL  MIONTAI.  DI8EASKS  207 

delusional  productions  arc  also  less  and  invariably  have  the  identical 
character  as  those  in  classic  paresis. 

Morbid  picture  of  agitated  paresis.  The  course  of  this  form  may 
be  illustrated  by  the  following  specific  case. 

A  substantial  baker  has  become  less  reliable  in  the  last  twelve 
years ;  with  unfortunate  inventions  and  speculations  he  has  squandered 
a  neat  little  fortune.  Suddenly  he  becomes  more  restless,  stays  away 
from  home  very  often,  though  to  be  sure  he  gives  definite  excuses,  he 
no  longer  wants  to  tend  his  oven  himself,  etc.  Several  months  later  a 
hallucinatory  delirium  breaks  out  very  suddenly,  voices  command  him 
to  undress  completely,  to  partake  of  only  three  mouth fuls  of  food  at 
each  meal,  and  to  cut  off  three  of  his  fingers.  Brought  into  the  insti- 
tution, he  throws  together  everything  he  lays  hands  on,  pours  the  soup 
into  the  plate  and  back  into  the  bowl  and  then  again  into  the  plate 
until  everything  is  on  the  floor ;  day  and  night  he  pounds  on  the  doors, 
tears  things  up,  jumps  around,  attacks  the  attendants  in  a  brutal  way, 
fails  to  recognize  his  surroundings,  and  does  not  permit  his  attention 
to  be  held  in  any  way.  His  talks  appear  entirely  incoherent.  Be- 
sides he  has  the  physical  signs  of  paresis.  After  about  a  week  he  is 
completely  exhausted,  permits  himself  to  be  kept  in  bed,  at  first  with 
the  aid  of  hypnotics,  but  he  is  still  in  incessant  motion,  which  in  the 
meantime  quickly  appears  weaker  and  less  systematic  and  after 
another  week  he  dies  from  exhaustion. 

Anatomical  Findings.  In  paresis  the  nervous  elements  of  the  brain, 
and  often  those  of  the  spinal  cord  also  gradually  disintegrate,  and 
to  be  sure  in  different  ways,  without  anything  in  common  to  the  de- 
structive processes  being  known.  The  arrangement  of  the  ganglia 
cells  in  rows  and  layers  seems  disturbed.  The  glia  grows  profusely 
in  the  cells  and  fibres  and  in  such  a  manner  that  these  elements  seem 
to  be  increased  and  enlarged,  that  is  to  say  thickened.  This  increase 
can  readily  be  differentiated,  even  on  superficial  examination,  from 
the  increase  of  the  glia  in  senile  forms,  by  the  degree  of  the  increase, 
and  specially  by  the  marked  thickening  of  the  elements.  INIitoses  of 
the  glia  cells  are  not  rare.  The  sheaths  of  the  smaller  vessels  of 
the  cortex  and  pia  (and  even  of  other  organs)  are  infiltrated  with 
round  cells,  which  usually  show  the  character  of  plasma  cells.  This 
latter  finding  is  said  to  be  characteristic  of  paresis,  as  it  only  is  met 
elsewhere  in  the  African  sleeping  sickness  and,  according  to  v.  Mona- 
kow,  in  multiple  sclerosis.  Other  frequent  alterations  of  the  vessels  of 
an  atheromatous  or  other  degenerative  character  are  probably  com- 
plications. The  formation  of  new  capillaries  is  often  plainly  observed. 
In  the  tissues  are  sometimes  found  the  red  cells  described  by  Nissl, 


268  TEXTBOOK  OF  PSYCHIATRY 

"very  elongated,  uncommonly  narrow  formations,  at  times  curved, 
which  consist  almost  only  of  a  single  bright  nucleus  with  several 
nucleolar  bodies,  beyond  which  the  body  of  the  cell  extends  at  both 
ends,  sometimes  more  and  sometimes  less."  Their  significance  is  not 
yet  evident.  Lately  spirochites  have  been  demonstrated  in  the  central 
organs  by  Noguchi  and  others. 

Macroscopically  the  brain  is  diminished, — in  very  old  cases  to  less 
than  1000  g.,  the  surface  has  frequently  lost  its  smoothness  as  a  result 
of  an  atrophying  process;  the  convolutions  are  narrowed,  and  the 
fissures  widened.  The  white  substance  is  of  a  dirty  discoloration  and 
often  contracts  in  the  plane  of  incision,  if  its  severer  atrophy  is  not 
concealed  by  (Edema  of  the  brain.  It  is  striking  that  for  the  clinical 
focal  manifestations  an  anatomical  substratum  is  not  always  found. 
But  sometimes  it  is  a  case  of  Lissauer's  paresis,  in  which  very  acute 
shifts  with  violent  cerebral  manifestations  have  affected  circumscribed, 
regions,  especially  in  the  occipital  region. 

The  findings  in  the  pia  do  not  stand  in  a  definite  relation  to  those 
of  the  brain.  But  the  usual  findings  are  as  follows :  The  pia  is  thick- 
ened and  opaque;  it  often  shows  adhesions,  sometimes  to  the  cortex, 
so  that  in  peeling  it,  parts  of  the  upper  cortical  layers  come  off 
(decortication),  and  sometimes  to  the  adjacent  folds  so  that  one  can 
only  go  through  the  median  fissure  or  the  fossa  Sylvii  with  the  help 
of  a  knife.  Microscopically  one  observes  an  increase  of  the  pia  tissues, 
round  cell  infiltration  (especially  plasma  cells)  and  the  identical 
changes  in  the  small  vessels  as  in  the  cortex. 

Nowhere  is  Pachymeningitis  haemorrhagica  found  so  frequently  as 
in  paresis,  and  often  the  dura  adheres  to  the  skull.  A  certain  weight 
has  been  attached  to  the  fact  that  the  diploe  is  frequently  lacking. 

Naturally  the  spinal  cord  shows  secondary  degenerations  as  a  re- 
sult of  the  changes  in  the  brain,  but  very  often  there  are  primary 
alterations  similar  to  those  in  the  brain. 

The  peripheral  nervous  system  sometimes  shows  chronic  degenera- 
tions. The  aorta  is  mostly  luetically  altered.  The  other  organs  also, 
above  all,  the  liver,  are  usually  not  normal;  but  more  definite  char- 
acteristics are  still  lacking.  The  ordinary  manifestations  of  lues  and 
their  remnants  are  remarkably  rare  (except  in  the  vessels)  in  paretics. 

Causes.  The  disease  which  is  now  differentiated  from  the  other 
organic  psychoses  as  paresis  is  in  the  same  sense  as  tabes,  a  "meta- 
syphilitic"  disease,  i.e.  at  the  present  time  it  is  a  late  manifestation 
of  lues,  hardly  ever  associated  with  ordinary  luetic  symptomg,  and 
uninfluenced  by  antiluctic  treatment.  According  to  statistics  of  army 
officers  about  4  percent  of  syphilitics  are  afflicted  later  with  paresis. 


THE  INDIVIDUAL  MENTAL  DISEASES  269 

Severe  or  mild,  thoroughly  or  superficially  treated  syphilis  may  be 
followed  by  paresis.  It  is  not,  however,  without  reason  that  some  speak 
of  a  special  "lues  nervosa"  which  is  said  to  run  an  easy  course  and  to 
dispose  one  to  tabes  or  paresis.  It  is  supposed  to  be  transmitted  as 
such  with  its  peculiarity.  However,  paresis  in  married  couples  is  not 
so  frequent  that  the  element  of  chance  be  excluded;  it  is  more  likely 
that  cases  of  paresis  with  a  common  source  of  infection  favor  this 
conception.  Since  tertiary  manifestations  are  practically  never  found 
in  people  having  paresis,  and  as  secondary  symptoms  of  lues,  also, 
are  infrequently  noticed  in  the  anamneses,  it  may  be  assumed  that 
the  mild  forms  of  lues  are  especially  predisposed  to  paresis.  But  it 
may  be  that  the  tertiary  and  the  metasyphilitic  symptoms  are  mutually 
exclusive.     At  all  events  it  is  striking  that  in  marital  infection  from 


Fig.  8. — Paresis.    Plasma  cells  on  the  wall  of  a  capillary. 

a  paretic  the  lues  is  latent  much  more  frequently  than  is  otherwise  the 
case.  What  the  personal  predisposition  to  this  kind  of  brain  lues  is, 
no  one  knows;  that  paresis  is  the  psychosis  of  the  healthy  brain  has 
been  supposed  with  just  as  little  reason  as  that  it  appears  only  in 
cases  of  psychopathic  heredity.  However,  in  the  previous  history  of 
many  paretics  a  very  unsteady  manner  of  living  is  found,  and  Savage 
once  called  attention  to  the  fact  that  the}-  have  mostly  taken  wives 
of  a  markedly  sexual  type.  Where  this  type  is  the  exception  as  in 
Switzerland,  this  can  be  confirmed.  Reichardt  claims  to  have  demon- 
strated a  small  cranial  capacity  as  very  frequent  in  paresis. 

That  mental  exertion  is  an  important  factor  has  not  been  proven. 
But  it  is  probable  that  alcoholism  plays  an  important  part  among 
those  predisposed,  because  paresis  is  extremely  rare  among  those  who 
have  been  total  abstainers  from  youth.  On  the  other  hand  there  is 
a  racial  predisposition  which  we  do  not  as  yet  understand.     Among 


270  TEXTBOOK  OF  PSYCHIATRY 

the  natives  of  the  Balkan  States  it  is  rare;  among  African  Arabs, 
Abyssinians  and  Australian  negroes  it  seems  practically  never  to  occur; 
with  the  Japanese  it  is  said  to  have  become  more  frequent  only  in 
the  last  decades;  with  the  negroes  of  North  America  it  was  formerly 
rarer,  now  it  is  especially  frequent.  It  is  much  rarer  in  rural  dis- 
tricts than  in  cities.  The  deciding  factor,  therefore,  is  probably  not 
the  race  as  such,  but  the  manner  of  living  or  some  added  determining 
cause,  e.g.  a  second  infection  of  a  different  sort. 

As  precipitating  or  secondary  causes  one  names  mental  exertions, 
heat,  traumata,  and  other  influences,  but  none  of  these  assumptions 
have  even  been  confirmed.  The  various  injurious  consequences  of  the 
war  have,  as  far  as  known,  conditioned  no  noticeable  increase  of 
paresis.  Nevertheless  injury  in  the  service,  be  it  in  the  sense  of 
causation  (precipitation)  or  in  the  sense  of  merely  aggravating  the 
disease,  was  assumed  after  over-exertions,  head  trauma,  infectious 
diseases,  etc.     Scientific  proofs  of  such  connections  are  still  lacking." 

Paresis  appears  most  frequently  from  about  eight  to  twenty  years 
after  the  syphilitic  infection;  but  there  are  also  belated  cases  and  those 
that  become  manifest  after  a  fewer  number  of  years  (up  to  two  years) . 
The  disease,  therefore,  occurs  in  the  period  of  most  active  endeavor, 
after  the  man  has  established  a  family  (maximum  between  35  and  45) 
and  thereby  attains  an  especially  great  social  significance.  To  be 
sure  there  are  cases  of  infantile  paresis,  that  are  based  on  hereditary 
lues  and  that  mostly  run  a  course  following  the  type  of  the  simple 
demented  form.  In  contradistinction  to  many  other  manifestations 
of  hereditary  lues  they  break  out  mostly  after  the  sixth  year,  indeed 
in  some  cases  not  until  around  the  age  of  twenty. 

In  accordance  with  its  nature  the  male  sex  is  much  more  fre- 
quently afflicted  than  the  female,  but  the  morbidity  of  the  latter  is 
rapidly  increasing,  especially  in  the  large  cities,  where  the  proportion 
is  one  to  two,  while  the  average  proportion  may  be  still  about  one  to 
four.  Men  are  afflicted  relatively  more  in  the  upper  classes,  while 
women  in  the  lower.  Cases  of  infantile  paresis  are  naturally  equally 
divided  between  two  sexes. 

Pathology.  The  finding  of  spirochites  in  the  brain  tissues  and 
of  plasma  cells  in  the  walls  of  the  vessels  shows  that  it  is  a  question 
of  a  direct  manifestation  of  lues  in  the  brain.  Whether  it  is  a  par- 
ticular species  of  spirochites,  an  inherited  predisposition  of  the  patient, 

"  Compare  especially  Bonnlioffer,  Die  Dienstbesehadigungsfrage  in  der  Psy- 
chopathologie.  Die  Militariirztliche  Sachverstandigentatigkeit  auf  dem  Gebiet 
des  Ersatzwesens.  Vortrage  .  .  .  redigiert  von  Adam.  Vol.  1.  Fischer,  Jena 
1917,  p.  86. 


THE  INDIVIDUAL  MENTAL  DISEASES  271 

or  later  additional  infiucnocs  that  make  a  case  of  parcsiH  out  of  a 
case  of  lues  is  not  known.  Racial  dispositions  may  be  variously  in- 
terpreted; that  paretics  are  somewhat  more  burdened  with  psychoses 
and  neuroses  than  the  normal,  even  though  less  burdened  than  the 
insane,  and  that  they  themselves,  for  the  most  part,  had  something 
psychopathic  about  them  even  before,  seems  to  point  to  endogenous 
influences;  on  the  other  hand,  the  additional  effects  of  alcohol  point 
to  exogenous.  It  is  interesting  that  cases  of  paresis  from  manic  de- 
pressive families  have  a  particular  inclination  to  the  affective  forms, 
while  those  with  schizophrenic  relatives  get,  by  preference,  paresis 
colored  in  the  sense  of  schizophrenia.  Besides  alcohol  we  do  not  know 
any  contributing  causes  that  are  favoring  or  necessary  to  the  origin 
of  the  disease. 

Diagnosis.  In  the  prodromal  stage  it  is  necessary  to  seek  the 
premonitory  symptoms  enumerated  above,^*  among  w^hich  migrain 
with  or  without  scintillating  scotoma  may  be  mentioned  when  it  has 
rather  suddenly  appeared  in  the  critical  age,  and  is  not  inherited; 
furthermore  all  premonitory  symptoms  of  tabes,  such  as  the  crisis 
and  above  all  pains  of  uncertain  origin  falsely  interpreted  as  rheumatic. 

The  organic  disease  is  confirmed  by  the  affective  state  and  the 
associations,  the  dementia  by  the  lack  of  critical  faculty  and  the 
kind  of  delusions,  and  the  paresis  in  particular  by  the  somatic 
symptoms. 

The  diagnostic  significance  of  the  individual  psychic  sj'mptoms 
may  be  inferred  from  what  has  been  said.  Prodromal  violations  of 
ethical  principles  by  people  formerly  decent  are  perhaps  the  only 
ones  that  should  be  particularly  mentioned  here. 

The  physical  symptoms  without  certain  proof  of  an  existing  mental 
disease  can  in  themselves  be  generally  decisive.  Paresis  has  the  char- 
acteristic pupillary  disturbance  in  common  with  the  other  luetic 
psychoses  and  tabes;  encephalitis  lethargica  also  at  times  leaves  pupils 
that  are  irresponsive  to  light.  Unequal  pupils  occur  persistently  in 
normal  people,  then  also  in  catatonia,  but  they  usually  change  quickly, 
while  in  paresis  they  change  at  the  most  in  the  course  of  weeks  and 
months.  Sluggishly  reacting,  or  rigid  pupils  are  often  found  in  the 
alcoholic  psychoses  with  an  organic  element,  very  rarely  in  the  hysteric 
with  contraction  of  sphincters,  then  in  the  epileptic  in  the  course  of 
the  attack,  etc.  One  must  hear  the  paretic  speech  disturbance  but  after 
that,  one  very  rarely  mistakes  it.  The  stuttering  of  imbeciles  is  some- 
thing entirely  different;  here  the  sounds  may  be  inexact  but  they  are 
not  misplaced  and  are  not  run  together;  on  the  contrary  they  are 
"  Cf.  D.  257. 


272  TEXTBOOK  OF  PSYCHIATRY 

combined  less  than  in  skilled  speech.  The  dysarthritic  disturbances  of 
other  organic  brain  diseases  have  not  yet  been  sufficiently  described, 
even  though  they  are  in  most  cases  easily  differentiated  from  those  of 
paresis.  One  has  to  think  only  of  the  hesitating  and  singing  of  epileptic 
speech  to  recognize  it  when  it  is  developed.  Yet  slightly  developed 
speech  disturbances  in  paresis  and  epilepsy  can  have  a  certain 
similarity. 

The  speech  disturbance  must  often  be  looked  for.  For  this  purpose 
one  finds  useful  some  test  words  which  make  a  great  demand  on  co- 
ordination: Above  all  "Third  riding  artillery  brigade,"  or  "Elec- 
tricity," or  "Methodist  Episcopal  Church,"  where  the  patient  usually 
gets  stuck  on  the  p  and  s  sounds,  or  "Around  the  rugged  rock  the 
ragged  rascal  ran."  Such  long  test  words  as  "Constantinopolitan 
ladies"  are  not  as  good  as  those  cited,  and  test  more  the  psychic 
qualities  like  attention  and  correct  reproduction,  than  coordination. 
One  must  particularly  learn  to  distinguish  between  psychic  and  speech 
errors.  He  who  instead  of  "Third  riding  artillery  brigade"  repeats 
without  coordinating  disturbances  "third  artillery  brigade"  is,  to  be 
sure,  usually  an  organic  case  but  seldom  a  paretic.  Furthermore,  it 
must  be  considered  that  many  patients  by  strained  attention  succeed 
even  with  difficult  words,  while  in  ordinary  conversation  they  fall 
down  on  more  simple  ones;  or  the  paretic,  who  has  been  examined  by 
several  physicians  in  succession,  is  specially  practiced  in  the  test 
words  and,  therefore,  reproduces  them  particularly  well.  On  the 
other  hand  anxious  attention  may  in  itself  cause  the  downfall  even 
of  those  not  suffering  from  paresis  in  the  speech  stunts  of  the  tests. 
In  many  cases  this  danger  may  be  circumvented  by  permitting  the 
patient  to  read  something  aloud,  and  this  can  be  done  with  better 
results  when  the  patient  is  not  aware  that  his  speech  is  tested. 

The  handwriting  cannot  always  be  evaluated  because  it  is  changed 
in  a  similar  manner  by  other  diseases,  and  the  results  of  severe  trem- 
bling are  sometimes  difficult  to  distinguish  from  those  of  disturbances 
of  coordination.  But  the  examination  of  the  handwriting  need  not 
be  dispensed  with,  and  in  cases  where  the  diagnosis  is  definite  the  exam- 
ination of  previous  handwritings  is  sometimes  the  safest  means  of 
determining  how  long  ago  the  disease  began.  Moreover,  in  an  existing 
psychosis  it  can  at  least  present  evidence  of  a  cerebral  affection,  which 
in  most  cases  indirectly  assures  the  existence  of  paresis.  Neurasthenics 
and  other  excited  people,  also,  sometimes  make  mistakes  in  handwriting 
both  as  to  quality  and  quantity  that  are  difficult  to  understand.  But 
they  can  easily  correct  them;  on  the  other  hand  the  person  afflicted 
with  paresis  leaves  most  of  his  errors  uncorrected,  he  also  cannot  readily 


THE  INDIVIDUAL  MENTAL  DISEASES  273 

find  them  and  when  he  does  make  corrections  they  are  very  often 
wrong. 

Paralyses  are  also  significant  when  it  is  certain  that  they  have  been 
acquired  wliich,  e.g.  in  the  case  of  facial  inequalities,  is  not  always 
easily  determined. 

Paralytic  attacks  are  often  mistaken  for  apoplectic  attacks  but  in 
the  latter  the  protracted  twitchings  arc  rare.  Apparently  severe  attacks 
with  consequent  paralyses  and  very  rapid  complete  recover^'  point  to 
paresis. 

To  be  sure  the  easiest  way  to  make  the  diagnosis  at  present  is 
through  an  examination  of  the  cerebro  spinal  fluid.  If  pieocytoses, 
Nonne  and  Wassermann,  are  found  in  an  existing  psychosis,  the  diag- 
nosis is  as  good  as  settled.  To  be  sure  tabes  can  produce  the  identical 
manifestation;  but  their  existence  only  increases  the  probability  of 
paresis  because  with  the  rarity  of  "tabes  psychoses"  in  the  narrower 
sense,  a  mental  disease  combined  with  tabes,  is  very  probably  paresis. 
In  some  exceptional  cases  of  paresis  the  Wassermann  findings  may  at 
times  be  negative  for  a  shorter  or  longer  period ;  this  is  mostly  the  case 
in  stealthy  or  stationary  stages  or  in  very  slowly  progressing  varieties. 
Cave:  In  the  secondary  stage  of  syphilis  one  sometimes  observes  in 
the  cerebro  spinal  fluid  the  same  findings  as  in  paresis,  but  its  only  sig- 
nificance is  that  it  is  a  transient  mild  cooperation  in  the  infection  on 
the  part  of  the  central  nervous  system  and  its  integuments.  Paresis 
at  this  period  is  extremely  rare. 

The  differential  diagnosis  of  manic  paresis  from  the  manic  attack 
of  manic  depressive  insanity  rests  on  the  demonstration  of  the  physical 
symptoms,  also  on  a  thoughtlessness  and  lack  of  regard  in  all  actions 
which  are  exaggeratedly  out  of  proportion  to  the  excitement,  and 
above  all  on  the  foolishness  of  the  delusions.  Mistaking  individuals  is 
rather  a  trick  with  manic  depressives;  whereas  paretics  believe  in 
their  fictions.  But  particular  care  must  be  taken  in  the  case  of  initial 
outbreaks  during  manhood,  because  paretic  symptoms  that  are  lacking 
today  may  appear  tomorrow.  At  anj'  rate  in  a  pronounced  manic 
state  of  paresis  the  delusions  are  nearly  always  present. 

The  differentiation  from  states  of  melancholia  rests  on  the  same 
principles. 

As  against  schizophrenia  the  diagnosis  is  often  not  easy,  when  we 
have  mere  conditions  of  excitements  with  a  senseless  and  confusional 
trend  of  ideas  which  do  not  assume  a  distinct  and  specific  form.  Indi- 
vidual catatonic  signs,  which  under  such  circumstances  usually  cannot 
be  anaylzed,  are  not  yet  evidence  of  catatonia,  but  affective  stiftness 
and  lack  of  intellectual  and  affective  rapport,  furnish  such  proof.    Since 


274  TEXTBOOK  OF  PSYCHIATRY 

so  many  paretics  were  always  pronounced  psychopaths,  the  anamnesis 
may  often  only  confuse  instead  of  enlighten.  Here,  as  in  all  psycho- 
pathies, it  is  often  of  decisive  importance,  if  from  a  definite  time  a 
change  of  the  psychic  attributes  in  the  sense  of  paresis  can  be  ascer- 
tained or  excluded. 

As  against  epilepsy,  only  the  specific  signs  of  the  two  psychoses 
can  be  decisive ;  when  epileptic  attacks  appear  in  middle  age,  they  are 
mostly  not  pronounced  in  any  direction,  and  therefore  there  are  cases 
where  for  a  time  one  wavers. 

Because  of  the  tendency  of  paretics  to  excesses  the  alcoholic  forms 
frequently  give  occasion  for  doubt.  Korsakoff's  disease  as  an  organic 
psychosis  has  the  most  important  psychical  symptoms  in  common  with 
paresis,  but  the  neuritis  and  the  lack  of  the  specific  paretic  signs 
(pupillary  disturbances  also  occur  there!)  usually  remove  the  diffi- 
culties; sometimes  the  mode  of  onset  of  the  disease  also  helps  the 
diagnosis.  But  the  peripheral  neuritis  is  not  always  present.  Alcoholic 
pseudo  paresis  causes  still  greater  difficulties.  I  have  never  seen  pro- 
nounced delusions  of  grandeur  accompany  it,  but  it  is  said  to  occur  in 
rare  cases.  Progression  during  abstinence  instead  of  gradual,  and  at 
least  partial,  regression  decides  in  time  for  paresis.  To  be  sure  the 
examination  of  the  spinal  fluid  is  a  quicker  way. 

Not  at  all  seldom  it  is  a  delirium  tremens  that  first  brings  the  real 
case  of  paresis  into  the  institution.  The  former  passes  away,  the  latter 
progresses. 

The  paranoid  forms  of  dementia  paralytica  are  very  rare,  sO'  that 
here  I  would  like  only  to  call  attention  to  them;  if  the  symptoms  are 
still  barely  pronounced,  then  for  a  time  the  differentiation  from 
paranoia  or  paranoid  states  can  only  be  made  by  lumbar  puncture. 

The  differential  diagnosis  from  brain  tumors  is  self-evident,  only 
it  must  be  mentioned  that  there  are  slowly  growing,  infiltrating  gliomas 
which  may  run  their  course  entirely  under  the  picture  of  a  simple 
paresis  with  indicated  local  symptoms.  Without  a  lumbar  puncture 
one  can  miss  the  diagnosis  up  to  death,  and  it  is  just  in  the  case  of 
suspected  tumor  that  the  puncture  is  dangerous. 

From  the  remaining  organic  psychoses  paresis  can  be  certainly 
differentiated  only  by  the  physical  symptoms  (including  the  fluid), 
even  though  pronounced  paretic  grandiose  delusions  alone  permit  the 
diagnosis  without  too  great  a  risk. 

To  draw  the  boundary  line  between  neurasthenia  and  paresis  is  one 
of  the  most  important  problems.  The  complaints  are  frequently  the 
same  for  a  long  time.  The  neurasthenic  supposes,  e.g.  that  he  is  suffer- 
ing from  weakness  of  memory ;  but  when  he  is  examined  for  it  nothing 


THE  INDIVIDUAL  MENTAL  DISEASES  275 

is  found,  or  instead  one  sees  affective  memory  difficulties;  he  fears  he 
is  suffering  from  "softening  of  the  brain"  and  thinks  he  has  a  speech 
disturbance,  but  the  hitter  shows  itself,  when  it  is  present  at  all,  to  be 
graduated  not  according  to  the  articulatory  difficulties  of  the  words, 
but  according  to  the  momentary  degree  of  anxiety.  Especially  im- 
portant is  the  attitude  of  the  patient  toward  these  symptoms.  The 
neurasthenic  pictures  everything  as  more  difficult  than  it  is;  he  likes 
to  hear  himself  consoled  but  is  not  quieted  immediately,  or  at  all.  The 
paretic  usually  does  not  take  matters  so  seriously;  he  very  readily 
offers  excuses:  Just  at  present  he  is  somewhat  tired  or  frightened  by 
the  examination  or  he  is  chilly  or  anything  similar.  And  when,  in 
depressive  cases  he  really  is  anxious,  he  remains  inconsistent  and 
readily  neglects  the  physician's  directions  which  the  real  neurasthenic 
does  only  when  he  is  bothered  by  several  "Systems  of  Treatment." 
Above  all  the  neurasthenic  shows  an  exaggerated  self-observation  and 
is  accustomed  to  attribute  an  exaggerated  importance  to  the  symptoms 
while  the  paretic  usually  appears  indifferent  and  exhibits  a  striking 
incapacity  for  self-observation.  This  difference  is  also  seen  in  the 
depressive  conditions  with  retained  intelligence  (e.g.  in  the  manic 
depressive  states). 

Treatment.  Prophylaxis  consists  in  the  avoidance  of,  or  combatting 
syphilis  and  alcohol,  the  latter,  because  on  the  one  hand  it  increases 
the  chances  of  infection,  on  the  other  hand  because  it  helps  lues  to 
develop  into  paresis.  It  has  not  been  proven  that  the  energetic  treat- 
ment of  erupted  syphilis  betters  the  chances  against  later  affliction 
with  paresis.  It  is  not  a  rare  technical  blunder  to  prophesy  the 
approaching  paresis  (or  tabes)  to  patients  with  pupillary  rigidity  or 
absent  patellar  reflexes.  If  later  difficulties  are  to  be  anticipatedj  a 
responsible  person  should  always  be  informed  of  the  possibility  of 
the  future  outbreak  of  such  a  disease;  the  patient  himself,  who  breaks 
down  anyway  at  the  critical  moment,  should  be  spared  and,  when 
possible,  his  wife  also. 

The  treatment  of  pronounced  paresis  as  a  disease  has  so  far  been 
hopeless.  Antisyphilitic  treatment  as  well  as  salvarsan  are  ineffective. 
Very  recently  successes  have  been  reported  from  the  infection  of 
patients  with  tertian  plasmodium  (Wagner  v.  Jauregg) . 

An  early  diagnosis  is  most  important,  in  part  to  save  the  expense 
of  ruinous  and  useless  treatments,  in  part  to  secure  the  existing  estate. 
When  cases  of  paresis  come  into  hospitals,  they  have,  in  great  part, 
impaired  their  estate  severely  as  a  result  of  their  grandiose  delusions 
or  of  the  dementia.  It  is  the  duty  of  the  family  physician  to 
instigate  the  necessary  steps  in  time.    Above  all  there  is  danger  in 


276  TEXTBOOK  OF  PSYCHIATRY 

the  long  remissions  upon  which  judges  and  relatives  like  to  look  as  a 
cure,  whereas  the  existing  feeble-mindedness  and  the  euphoric  mood 
as  well  as  new  shifts  impair  the  patient's  capacity  for  independent 
action. 

The  obvious  general  rules  of  treatment  should  be  followed  in  the 
excitements  as  well  as  in  the  stage  of  helplessness.  In  anxiety  states 
opiates  often  render  good  service.  Careful  oversight  of  the  bladder  is 
essential,  as  otherwise  paradoxical  incontinences  remain  concealed  and 
may  lead  to  paralysis  or  rupture  of  the  bladder.  Many  patients  can 
under  favorable  circumstances  be  treated  at  home  as  soon  as  it  is 
certain  that  they  will  permit  themselves  to  be  managed,  and  will  not 
endanger  their  estate  or  compromise  themselves  by  sexual  excesses 
or  criminal  acts. 

In  paralytic  attacks  a  simple  conservative  attitude  is  best;  the 
patients  are  protected  from  harm  through  collision  and  rubbing,  but 
above  all  against  uncleanliness.  Artificial  feeding  is  resorted  to  only 
in  cases  of  necessity;  the  patient  will  not  die  at  once  from  inanition 
but  with  these  helpless  patients  the  danger  is  especially  great  that 
some  of  the  liquid  food  is  inhaled  into  the  lungs  when  the  tube  is  taken 
out  or  when  they  gag.  Nutritive  enemas  are  often  not  retained.  When 
necessary  an  infusion  of  a  physiological  salt  solution  beneath  the  skin 
can  at  least  maintain  the  supply  of  water  at  the  proper  level.  If  the 
relatives  demand  "that  something  be  done,"  ice-packs  applied  to  the 
head  are  advisable,  and  amylenehydrate  or  paraldehyde  or  chloral- 
amide  are  said  to  reduce  sometimes  the  violence  of  the  convulsion. 
The  first  two  drugs  can  also  be  given  as  an  enema  in  a  vehicle  that 
protects  the  bowel  (chloralamide  4.0  to  6.0  (!),  Amyli  4.0,  Ap.  dest. 
150.0;  or  Amylenehydrate  4.0  to  6.0  Aq.  dest.  60.0,  Mucil  Gummi  arab. 
30.0  for  enema).  Heart  stimulants  are  also  given,  when  a  collapse  is 
threatened. — But  I  do  not  have  the  impression  that  the  attack  runs 
its  course  the  worse  in  any  respect  whatever,  if  the  patient  is  not 
bothered  at  all. 

V.     SENILE  AND  PRESENILE  INSANITY  (SENILE 
PSYCHOSES) 

Under  the  name  of  senile  psychoses  Kraepelin  includes  the  presenile 
and  senile  mental  disturbances,  among  the  latter  separating  arterio- 
sclerotic insanity  from  senile  dementia  with  which  he  also  classes 
presbyophrenia. 

The  presenile  forms  are  as  yet  symptomologically  as  well  as  sys- 
tematically entirely  obscure.    It  has  not  even  been  definitely  proven 


THE  INDIVIDUAL  MENTAL  DISEASES  277 

that  there  are  such  forms.  No  doubt  certain  forms  are  favored  at  the 
period  of  involution  since,  c.^,.  depressions  and  anxiety  states  increase 
greatly  from  this  time  on  and  it  is  possible  that  certain  psychoses  still 
occur  in  this  period.  The  morbid  pictures  here  considered  as  presenile 
are  with  difficulty  separated  from  the  senile  forms,  in  part  because  a 
few  of  them  also  evince  an  organic  character,  in  part  because  naturally 
in  case  of  a  protracted  duration  a  senile  brain  alteration  may  very 
easily  be  added  to  the  presenile,  in  which  case  the  furtive  development 
of  the  organic  symptom  for  a  long  time  easily  conceals  the  fact  that 
something  new  has  stepped  in. 

The  conception  of  "Involution"  which  is  infused  with  the  idea  of 
"presenility,"  is  sometimes  conceived  in  the  sense  of  a  regression  that 
ends  with  death,  sometimes  in  the  sense  of  transition  to  a  new  age, 
similar  to  the  "climacterium":  The  designation  "Involutionary  Psy- 
choses" is  based  on  the  latter  conception,  directing  attention  to  a 
difference  as  opposed  to  the  senile  psychoses. 

The  actual  senile  (psychoses,  that  we  know,  all  have  a  definite 
tendency  to  progress,  or  expressed  anatomically,  to  the  gradual  destruc- 
tion of  the  brain.  That  there  are  not  also  curable  psychoses  belonging 
to  senility,  is  naturally  not  excluded  as  yet.  But  with  these  I  should 
not  like  to  class  "senile  melancholias"  with  mild  organic  features  or 
organic  confusions  and  deliria,  because  on  closer  examination  it  is 
always  found  that  after  the  disappearance  of  the  striking  symptoms 
the  patient  is,  in  the  sense  of  dementia  senilis,  a  weakened  individual. 
Therefore,  I  conceive  such  storms  as  intercurrent  manifestations  of  a 
senile  brain  degeneration,  just  as  in  pronounced  senile  dementia  and 
analogous  to  the  acute  appearances  in  paresis  and  schizophrenia,  and 
theoretically  I  place  the  major  disease  in  the  foreground,  even  though 
there  are  cases  where  the  restoration  of  equilibrium  has  practically 
the  significance  of  a  cure.  On  the  other  hand  Kracpelin  usually  places 
the  practical  result  in  the  foreground  and  designates  many  senile 
melancholias  with  nihilistic  delusions  or  other  organic  manifestations 
as  curable,  as  long  as  the  psyche  is  not  as  yet  materially  damaged 
otherwise. 

Furthermore  other  psychoses,  like  manic  depressive  shifts,  which 
also  oecur  at  this  age,  naturally  do  not  belong  to  the  senile;  here  the 
disposition  lies  in  the  native  constitution  and  not  in  the  age. 

The  senile  psychoses  offer  three  different   classes  of   anatomical 

findings:    arteriosclerosis    with    its    effects    on    the    nervous    system 

{arteriosclerotic  insanity),   simple   atrophy   of  the   brain    {dementia 

senilis  in  the  narrower  sense)  and  spherotrichia  {Vcrdrusung')  with  or 

'without  alteration  of  the  neuro-fibrils    {presbyophrenia) .     With   the 


278  TEXTBOOK  OF  PSYCHIATRY 

first  and  last  alteration  there  naturally  also  appears  regularly  sooner 
or  later  a  nutritive  disturbance  of  the  entire  brain  and  besides,  the 
three  processes  can,  from  the  beginning,  be  combined  in  all  possible 
combinations.    We  rarely  have  pure  forms  in  practice. 

The  essential  thing  is  above  all  anatomically  the  diffuse  reduction 
of  the  brain  substance  and  symptomatologically  the  complex  of  the 
"organic  psychic"  symptoms.  The  latter  alone  are  present  in  the 
simple  senile  forms.  In  arteriosclerotic  insanity  there  are  also  neuro- 
logical cerebral  manifestations  and  the  psychical  defects  for  a  long  time 
have  something  lacunar  about  them.  In  the  presbyophrenic  forms  the 
picture  is  complicated  by  excitation  and  some  other  symptoms. 

The  three  senile  forms  have  within  the  organic  group  a  common 
differential  diagnosis,  which,  as  against  paresis,  is  decided  chiefly  by 
the  absence  of  the  paretic  signs  (speech,  pupils,  fluid,  blood  Wasser- 
mann) .  As  against  alcoholic  Korsakoff  the  decisive  points  are  the  lack 
of  the  signs  of  alcoholism  and,  up  to  a  certain  degree,  neuritis.  The 
remaining  organic  diseases  (brain  tumor,  multiple  sclerosis,  etc.)  carry 
their  particular  neurological  signs  which  are  wanting  in  the  psychoses 
previously  mentioned. 

The  alcoholic  Korsakoff  patient  is  as  a  rule  euphoric  in  the  begin- 
ning but  not  manic  as  in  classic  paresis.  The  deeper  moods  of  the 
senile  patients  are  in  the  great  majority  of  a  depressive  type. 

Organic  depressions,  especially  senile,  externally  often  closely 
resemble  late  catatonias  since  they  are  rebuffing  (like  negativism), 
mutistic,  and  have  moods  and  fits  (like  the  stereotype  forms).  The 
general  specific  signs,  especially  memory  defects,  may  still  be  absent 
in  the  beginning.  For  purposes  of  recognition  the  good  affective  reac- 
tions are  especially  of  service,  which,  to  be  sure,  may  manifest  them- 
selves only  in  little  noticeable  movements  of  the  corners  of  the  mouth ; 
then  also  the  accumulation  of  organic  delusions: — a  million  years  in 
purgatory,  the  abdomen  is  a  sewer,  it  is  blown  up  like  a  baloon  (^hile 
in  reality  it  is  entirely  empty  and  contracted).  Such  ideas  are  not 
excluded  in  dementia  prsecox  but  are  very  rare. 

A  number  of  therapeutic  viewpoints  also  are  common  to  the  group. 
Like  paresis  they  jeopardize  the  fortune  and  the  legal  relations  gen^ 
erally.  Therefore  in  every  individual  case  the  question  arises  whether 
a  legal  guardianship  should  be  instituted. 

Beware  of  the  advice  that  the  patient  should  give  up  the  accustomed 
occupation  without  a  substitute,  unless  it  is  absolutely  necessary. 
Senility  often  becomes  a  disease  only  as  a  result  of  the  sudden  cessation 
of  the  ordinary  attractions  of  life. 

Interning  in  an  institution  should  be  much  less  frequently  recom- 


THE  INDIVIDUAL  MENTAL  DISEASES  279 

mended  and  should  be  less  often  permitted  to  become  protracted  than 
in  a  case  of  paresis.  If  a  senile  patient  has  a  home,  under  ordinary 
circumstances  he  should  be  able  to  remain  there.  Only  when  acces.sory 
symptoms  (restlessness,  confusion)  or  danger  for  himself  and  those 
about  him  appear,  when  he  is  melancholic,  when  he  handles  light  and 
fire  carelessly,  leaves  the  gas  jet  open,  is  inclined  to  sexual  attacks, 
threatens  his  wife  and  children,— then  only  should  he  be  placed  in  an 
institution.  If  the  danger  is  past,  it  should  be  seen  to  it  that  he  is 
again  brought  into  normal  condition. 

The  nightly  deliria  which  are  very  annoying  to  all  concerned  may 
sometimes  be  overcome  by  hypnotics  but  not  nearly  in  all  cases. 
Besides  the  ordinary  remedies  bromidia  may  be  recommended  here 
which  contains  a  happy  combination  of  narcotics  precisely  for  just 
such  cases.  Its  formula  is  a  secret;  how  to  compound  it  is  stated 
below.^^  But  the  remedy  can  be  compounded  in  every  drug  store. 
Only  the  preparation  then  looks  cloudy  and  must  be  shaken.  Ris 
recommends  for  the  "reversed  daily  program"  (restlessness  at  night, 
sleep  during  the  day)  that  0.03  opium  be  given  evenings  around  eight 
o'clock;  after  one  or  two  weeks,  sleep  would  occur  at  night,  when  the 
remedy  can  be  omitted  until  further  needed.  In  severe  cases  two  doses 
(6  and  8  o'clock)  should  be  given;  a  triple  dose  daily  (4,  6  and  8 
o'clock)  should  rarely  be  necessary. 

Presenile  Insanity 

Under  this  name  are  described  entirely  different,  insufficiently 
classified  and  characterized  pictures:  1.  rare  subacute  cerebral  degen- 
erations which  result  in  death  or  dementia  often  after  a  few  months 
of  senseless  delusions,  delirium,  usually  anxiety  conditions,  and  which 
are  to  be  classed  with  diseases  of  the  brain.  2.  more  frequent  7nelan- 
choly  conditions  of  varying  appearance,  usually  improving  (see  manic- 
depressive  insanity  and  climacterium  virile) :  3.  prett}'  frequent  para- 
noid and  catatonia-like  forms,  the  former  passing  more  chronically,  the 
latter  rather  in  shifts,  but  on  the  whole  with  a  bad  prognosis.  A  part 
but  not  all  of  the  third  category  are  belated  schizophrenias.  According 
to  my  experience,  Kraepelin's  presenile  delusions  especially  belong  to 
dementia  prsecox. 

Arteriosclerotic  Insanity 

Arteriosclerotic  insanity  has  verj^  manifold  ways  of  manifesting 
itself.    Usually  arteriosclerosis  of  the  brain  with  different  symptoms 

"Ext.   Cannab.   Ind.   Ext.   Hyoscyami   fluid,   aa    0.5.     Kal.   bromat.   Chloral- 
hydrati  aa  50.0.    Aq.  dest.  ad  250.0. 


280  TEXTBOOK  OF  PSYCHIATRY 

is  present  before  a  psychosis  can  be  mentioned.  Very  few  cases  gen- 
erally reach  the  psychiatrist.  Arteriosclerosis  in  itself  does  not  con- 
dition a  psychosis ;  this  only  happens  when  there  is  a  diffuse  reduction 
of  the  brain  substance  (aside  from  transient  delirious  conditions  and 
the  emotional  disturbances  from  large  brain  lesions). 

The  neurologic  cerebral  symptoms  consist  of  head  pressure,  head- 
ache with  marked  fluctuations,  dizziness,  fainting  spells,  buzzing  in  the 
ears,  scintillating  before  the  eyes,  eventually  paralyses  and  all  possible 
focal  symptoms  such  as  hemiplegia,  hemianopsia,  and  aphasic  and 
apractic  disturbances  etc.  The  latter  manifestations  of  organic  de- 
terioration are  in  the  beginning  usually  unstable  and  can  regenerate 
very  decidedly  (i.e.  they  need  not  be  based  on  hemorrhage  and 
softenings) . 

In  very  many  cases  other  symptoms  also  appear  as  a  result  of 
arteriosclerotic  changes  in  other  organs,  especially  the  kidneys  and  the 
heart. 

As  long  as  the  psychic  symptoms  do  not  dominate  the  picture,  the 
disease  is  also  designated  as  "the  nervous  jorm  of  arteriosclerosis  of 
the  hrain." 

The  psychic  symptoms  like  the  physical  begin  very  insidiously  and 
come  and  go  in  the  beginning.  The  patients  often  feel  something 
like  a  void  in  their  mind,  their  initiative  weakens,  it  becomes  difficult 
for  them  to  rouse  themselves  to  action.  Their  endurance  is  diminished, 
the  accustomed  attention  is  trying  to  them,  they  tire  much  more 
readily  than  they  used  to.  These  symptoms  invariably  have  a  painful 
effect  whereby  the  morbid  picture  is  again  made  more  serious.  But 
undoubtedly  there  also  exists  a  primary  tendency  to  depression  and 
to  an  anxious  conception  of  experiences,  often  even  to  severe  anxiety 
conditions,  which  evidently  are  frequently  the  direct  result  of  circula- 
tory disturbances  of  the  brain. 

This  stage  may  last  for  years  without  material  aggravation.  Never- 
theless the  affectivity  usually  becomes  more  labile  in  a  certain  sense; 
emotional  incontinence  is  plainly  developed.  The  patient's  interest 
becomes  narrowed  and  the  tendency  to  depression  inhibits  somewhat 
the  emotional  fluctuations;  nevertheless  it  is  evident  how  they  can 
react  in  all  directions  in  the  sense  of  irritability  and  psychic 
pain,  and  in  periods  of  improvement  also  in  the  sense  of  joy  and 
longing,  and  what  is  characteristic  is  the  fact  that  they  react  even 
to  trifles. 

Gradually  disturbances  of  memory,  especially  for  recent  experi- 
ences, become  more  pronounced,  at  first  only  on  certain  occasions,  as 
on  seeking  a  name,  etc. ;  later  it  is  more  generally  noticeable,  but  always 


THE  INDIVIDUAL  MENTAL  DISEASES  281 

oscillating  up  and  down.  Confabulations  may  appear  but  are  rarely 
numerous. 

As  a  result  of  many  fluctuations  in  the  course  of  many  years  the 
picture  may  become  more  and  more  serious.  Anxiety  states  lasting 
for  minutes  or  weeks  can  assume  a  delirious  character  with  failure  to 
recognize  the  environment,  dreadful  delusions  of  being  cut  up,  burnt, 
buried  alive,  usually  as  punishment  for  sins.  The  patients  struggle 
for  breath,  yell,  accuse  themselves,  strive  to  get  away,  and  make  brutal 
attempts  at  suicide.  In  the  intervals  also  there  is  a  tendency  to  real 
melancholia.  The  patients  become  less  courageous,  they  are  timid, 
conceive  everything  as  painful,  and  form  depressive  delusions, 
especially  also  of  a  hypochrondriacal  type. 

Other  delirious  states  are  rather  rare  in  the  simple  forms,  but  they 
are  all  the  more  frequent  in  the  apoplectic  types. 

Apperceptive  ability  and  attention  are  only  gradually  changed  in 
the  sense  of  the  organic  syndrome. 

Orientation  at  first  suffers  only  spasmodically  and  finally  it  is  en- 
tirely destroyed,  the  physical  strength  is  impaired,  the  patients  finally 
remain  bedridden  and  die  of  marasmus  or  of  apoplectiform  attacks. 

Apoplectic  Forms.  Very  often  the  entire  disease  has  its  origin  in 
the  attacks  or  these  chiefly  determine  its  course.  Here  one  deals  with 
hemorrhages  as  well  as  softenings.  The  first  attack  occurs  after 
arteriosclerotic  prodromal  stages  of  varying  intensity  and  varying 
duration,  or  also  in  people  who  were  still  entirely  well,  with  the  usual 
symptoms  of  headache,  irritabilities,  dizziness,  fainting,  and  conse- 
quent general  symptoms  and  focal  manifestations,  the  latter  remaining 
or  regenerating  according  to  their  location.  Depending  on  the  general 
nutritive  condition  of  the  brain  and  perhaps  also  on  the  localization  of 
the  focus,  the  psychical  signs  of  diffuse  brain  atrophy  can  sooner  or 
later  supervene.  According  to  my  experience,  lesions  especially  in  the 
region  of  the  pons  seem  to  be  deleterious,  although  at  first  they  produce 
the  least  change  in  the  psyche  (circulatory  disturbances  starting  from 
the  vascular  centre?).  On  many  cases,  however,  the  psyche  remains 
for  years  disturbed  so  little  that  the  patients  are  properly  regarded  as 
mentally  sound.  Only  the  affectivity  is  often  plainly  changed  in  these 
cases  also,  and  this  change  is  in  the  direction  of  lability.  Often 
immediately  after  the  stroke  the  patients  can  be  made  to  cry  and  even 
to  laugh  much  more  readily  than  before.  In  many  cases  they  feel  this 
as  positively  unpleasant;  real  compulsive  laughing  and  compulsive 
crying,  i.e.  mimetic  expressions  to  which  no  real  felt  affect  corresponds 
qualitatively  and  quantitatively,  is  a  rare  local  symptom  emanating 
from  the  thalamic  region. 


282  TEXTBOOK  OF  PSYCHIATRY 

Otherwise  dementia  apoplectica  is  not  materially  different  from 
simple  arteriosclerotic  dementia  without  apoplectic  strokes  with  which 
it  is  connected  by  transitional  forms  with  rare  or  frequent  minor 
attacks. 

Both  forms  may  be  complicated  by  moods  (nearly  always  depres- 
sive), and  especially  by  irregular,  fluctuating  anxiety-melancholic 
states. 

Invariably  the  personality  with  its  strivings  is  maintained  for  a 
relatively  long  period;  even  when  the  patients  already  appear  decidedly 
demented  they  are  not  much  changed  in  the  fundamental  aims  of  their 
will,  only  they  no  longer  understand  everything  and  they  permit  them- 
selves to  be  dominated  more  by  their  affects.  The  symptoms  of  deteri- 
oration also  are  ''lacunary,"  i.e.  as  to  time  and  in  respect  to  special 
functions  they  are  entirely  irregular,  present  or  absent  in  part;  thus 
•good  memory  may  be  surprisingly  present  in  complete  helplessness  of 
the  ability  to  recall,  and  correct  judgments  may  be  evinced  side  by  side 
with  completely  narrowed  ones.  While  in  paresis,  dementia  senilis  and 
presbyophrenia,  one  can  infer  with  great  probability  from  the  general 
condition  as  to  individual  abilities,  in  this  case  it  would  be  very 
deceptive. 

Individually  the  pictures  are  naturally  very  different  according  to 
the  location  and  diffusion  of  the  lesion  on  the  one  side  and  according 
to  the  intensity  of  the  general  cerebral  atrophy  on  the  other. 

Concerning  the  course  of  all  forms  Kraepelin  emphasizes  the  fact 
that  first,  the  decrease  in  the  elasticity  of  the  vessels  produces  troubles 
in  the  adjustment  of  the  blood  apparatus  to  the  momentary  needs; 
this  adjustment  is  particularly  infinitely  graduated  in  the  brain.  This 
naturally  also  impairs  the  capacity  for  functional  adjustments  and 
consequently  produces  the  exhaustion,  the  difficulties  in  doing  things 
and  perhaps,  also  a  part  of  the  early  affective  disturbance.  It,  finally 
produces  wrong  reactions  of  the  vessels,  sometimes  surely  local 
paralyses  of  the  vessels,  which  causes  the  transient  local  troubles  and 
many  fluctuating  general  symptoms  Later  one  observes  an  insufficient 
blood  supply  of  circumscribed  regions  which  are  ever  increasing  in 
numbers,  sometimes  even  embracing  the  entire  brain  (e.g.  in  sclerosis 
the  entire  circulus  Willisii)  with  the  various  consequent  manifestations, 
and  in  the  third  place  the  hemorrhages  and  softenings  resulting  from 
the  breaking  of  the  arterial  walls  and  the  blocking  of  the  lumina. 

The  outcome  is  death  following  organic  dementia.  The  latter  may 
not  occur  when  the  course  is  shortened  by  apoplexies  and  other  attacks. 
The  duration  of  the  disease  may  vary  from  a  few  weeks  to  two  decades. 

Age.    Arteriosclerotic   insanity  appears  most  frequently  between 


THE  INDIVIDUAL  MENTAL  DISEASES  2H;i 

the  ages  of  55  and  65  years.  But  cases  occur  even  in  the  forties ;  they 
are  mostly  conditioned  by  a  family  predisposition. 

Both  sexes  are  about  equally  represented  in  the  apoplectic  disturb- 
ances, in  the  other  forms,  according  to  Kraepelin,  7L5%  affect  men. 

A  functionally  limited  morbid  picture  is  arteriosclerotic  epilepsy, 
which  usualy  appears  very  early  in  the  various  localizations  of  arterio- 
sclerosis and  sooner  or  later  leads  to  dementia.  It  is  said  to  occur 
mainly  in  alcoholics. 

Concerning  the  anatomy  of  arteriosclerotic  insanity  nothing  can 
really  be  added  to  what  has  been  said.  Most  of  the  varieties  of  arterio- 
sclerotic thickening  through  proliferation  of  the  vascular  cells,  hyaline 
degeneration,  etc.  are  found  in  the  most  different  distributions,  and  as 
a  result  of  these  there  is  local  destruction  of  the  nerve  tissue  through 
degeneration  and  a  filling  in  of  glia  ("perivascular  gliosis"),  through 
capillary  and  large  hemorrhages,  through  softenings,  and  besides  in 
most  cases  there  is  a  diffuse  reduction  of  the  brain  substance  as  the 
expression  of  a  general  metabolic  disturbance.  The  sum  of  countless 
small  lesions  can  perhaps  also  have  the  same  effect  as  a  complete 
diffuse  disturbance.  The  entire  brain  is  invariably  atrophied ;  at  death 
it  is  reduced  on  an  average  by  about  150  g.  The  pia  is  often  thickened 
with  connective  tissue,  but  hardly  infiltrated  or  adherent. 

The  etiology  of  arteriosclerosis  is  for  the  most  part  still  obscure; 
it  is  not  only  a  disease  of  civilization;  its  traces  are  said  to  have  been 
found  in  prehistoric  races.  At  all  events  the  family  disposition  is  of 
importance.  On  the  basis  of  experimental  facts,  tobacco  has  been 
blamed  very  recently;  alcohol  for  a  long  time.  Furthermore  the 
attempt  has  been  made  to  include  among  the  causes  of  arteriosclerosis 
a  number  of  circumstances  such  as  conscientiousness  and  dissipation, 
overexertion  and  laziness,  and  many  other  things,  but  as  yet  without 
sufficient  proof.  In  the  ordinary  cases,  where  the  Wassermann  is  nega- 
tive lues  probably  plays  no  part;  as  yet  we  do  not  possess  sufficient 
knowledge  to  differentiate  anatomically  the  ordinary  arteriosclerosis 
from  the  specific  in  all  cases. 

As  precipitating  causes  debilitating  diseases  are  to  be  mentioned, 
as  in  simple  dementia  senilis;  the  brain,  the  blood  supply  of  which 
might  just  suffice  under  ordinar>^  circumstances;  can  then  no  longer 
obtain  nourishment  and  atrophies  in  toto  or  in  certain  places  to  such 
an  extent  that  the  psychic  symptoms  break  out.  Stronger  affects, 
especially  depressive  ones,  often  induce  the  rapid  appearance  of  the 
arteriosclerotic  syndrome;  the  connecting  link  is  probably  the  inade- 
quate regulation  and  adaptive  insufficiency  of  the  vessels. 

Naturally  in  pronounced  cases  the  diagnosis  is  relatively  easy. 


284  TEXTBOOK  OF  PSYCHIATRY 

In  the  beginning  it  is  based  on  the  different  neurological  symptoms 
with  their  characteristic  change. 

The  hardening  of  the  cerebral  vessels  is  not  always  easy  to  diagnose. 
More  severe  sclerosis  of  the  arteries  of  the  body  offers  a  certain  prob- 
ability of  similar  changes  in  the  brain;  but  the  latter  can  just  as  well 
be  free  in  the  case  of  pronounced  hardening  in  other  organs,  just  as  the 
reverse  occurs.  Importance  is  properly  attached  to  increase  of  blood 
pressure,  slow  pulse,  to  its  abnormal  increase  after  slight  exertions 
(climbing  on  a  chair  or  bending  ten  times),  then  especially  to  the 
marked  differences  between  systolic  and  diastolic  pressure.  The 
normal  figures  (measured  according  to  Recklinghausen)  are  minimum 
pressure  to  100  mm.  Hg.,  maximum  pressure  160  mm.  Hg.,  resp.  140 
and  220  cm.  HsO. 

From  paresis  which  is  sometimes  combined  with  arteriosclerosis, 
it  can  be  differentiated  by  the  absence  of  the  physical  signs  of  paresis, 
especially  pupillary  rigidity  which  is  never  found  here,  negative 
Wassermann  in  the  blood  and  fluid,  absence  of  pleocytosis  and  globulin 
reaction  in  the  fluid,^**  absence  of  expansive  delusions  and  excessive 
euphoria.  Manic  states  hardly  occur  in  arteriosclerotic  insanity. 
Anatomically  there  need  not  be  in  paresis  a  thickening  of  the  vessel 
walls,  while  the  infiltration  with  plasma  cells  is  foreign  to  arterio- 
sclerosis. 

From  dementia  senilis  and  presbyophrenia  it  is  differentiated  par- 
ticularly by  the  fluctuations  in  the  course  and  by  the  presence  of  the 
signs  of  arteriosclerosis.  Heredity  also  sometimes  offers  differential 
points.  When  there  are  no  circumstances  that  favor  cerebral  atrophy 
such  as  a  manic-depressive  constitution,  congenital  weakness  of  the 
brain,  alcoholism,  and  heart  troubles,  an  age  of  less  than  sixty-five 
years  speaks  against  mere  dementia  senilis.  But  it  is  self-evident  that 
the  various  senile  processes  frequently  take  place  together. 

Senile  dementia  and,  to  a  still  higher  degree,  paresis  alter  the  per- 
sonality much  earlier  and  fundamentally  than  arteriosclerosis;  the 
entire  functions  of  memory,  of  the  critical  faculty,  etc.  are  damaged 
in  senile  dementia  and  paresis  while  arteriosclerosis  at  least  for  a  long 
time  manifests  itself  in  a  "Mosaic  of  individual  symptoms." 

From  brain  syphilis  arteriosclerotic  insanity  is  differentiated  by 
the  absence  of  the  neurological  signs  (eye  troubles,  etc.)  and  by  the 
serological  signs  of  lues. 

Treatment.  Because  of  our  ignorance  of  the  etiology  we  cannot 
carry  on  much  prophylaxis  against  arteriosclerosis.  It  is  undoubtedly 
good  to  avoid  tobacco  and  alcohol.    Still,  pronounced  arteriosclerotic 

^"Increase  of  albumin  occurs,  as  it  seems,  but  no  globulin  reaction. 


THE  INDIVIDUAL  MENTAL  DISEASES  285 

insanity  is  in  many  cases  a  grateful  object  of  treatment.  Mild,  slowly 
progressing  disturbances  are  often  markedly  improved  and  there  is 
also  occasion  to  prove  that  this  is  not  chance  but  really  the  result  of 
treatment. 

It  is  very  often  possible  to  free  the  patients  from  all  the  p.sychic 
and  physical  exertions  that  they  cannot  bear,  that  is,  from  those 
burdens  which  according  to  experience  aggravate  their  condition.  If  it 
is  not  known  what  the  patients  can  stand,  it  is  necessary  to  try  them 
out  carefully.  Neither  the  psyche  nor  the  heart  should  be  overtaxed. 
As  far  as  possible  the  patients  should  be  protected  against  affective 
disturbances.  If  the  heart  does  not  respond  it  should  be  treated  but 
not  without  care  (digitalin;  once  in  a  while  perhaps  strophantus,  etc.: 
sensible  treatment  with  digitalis  hardly  increases  the  danger  of 
apoplexy).  We  also  have  had  good  results  with  diuretin  in  small  doses, 
e.g.  0.5  three  times  a  day.  Anxiety  states  can  also  be  combatted  from 
the  psychical  side  with  opiates  or  at  the  same  time  with  heart  remedies. 
Very  often,  too,  a  bromide  preparation,  especially  sedobrol,  produces 
calm;  it  can  be  combined  very  well  with  small  doses  of  iodide.  Iodide 
is  generally  given  and  under  certain  circumstances  it  probably  has  a 
certain  effect  on  the  arterial  walls  or,  at  any  rate,  on  their  regulation 
and,  as  has  been  lately  supposed,  on  the  viscosity  of  blood  also.  At 
present  many  are  afraid  of  such  big  doses  as  3.0  per  day,  and  prefer 
smaller  doses,  e.g.  up  to  0.5  per  day.  All  drugs  should  be  stopped  after 
a  few  weeks  or  months  until  there  is  a  new  indication  for  their  reappli- 
cation.  For  example,  an  iodide  cure  can  perhaps  be  given  once  ever>' 
year. 

Proof  is  lacking  that  any  of  the  usually  recommended  diets  are 
useful;  excessive  meat  diet  is  said  to  be  injurious.  Lewandoivsky 
claims  to  have  observed  benefits  from  a  diet  with  little  salt.  At  all 
events  the  patient  should  guard  against  overfilling  his  stomach  either 
with  solid  or  liquid  food.  Stimulating  substances  as  well  as  alcohol  -^ 
should  be  avoided  on  principle. 

The  psychic  treatment,  which  should  calm  the  anxious  patient  with 
consolations,  is  especially  important. 

But  under  all  circumstances,  as  soon  as  the  condition  permits,  the 
attempt  should  be  made  to  keep  the  patient  busy.  In  the  beginning 
of  the  disease  before  employment  has  been  given  up,  this  usually  suc- 
ceeds without  much  difficulty  by  having  the  patient  do  a  smaller 
amount  of  his  ordinary  work.  If  this  is  not  possible,  other  work  must 
be  sought  for  him  that  holds  his  interest.    Exercise  in  the  open,  adapted 

"Total  abstinence  from  alcohol  is  a  condition  sine  qua  nan  in  any  treatment. 
(Pilz,  Wiener  med.  W.S.  1910,  p.  626.) 


286  ,      TEXTBOOK  OF  PSYCHIATRY 

to  the  strength  of  the  heart,  is  naturally  to  be  recommended.  In  this 
way  fairly  tolerable  conditions  are  often  obtained  for  many  years. 
Naturally  this  is  also  the  case  when  the  arteriosclerosis  has  been 
complicated  by  an  involutionary  depression  independent  of  it,  which 
heals  in  time  of  its  own  accord,  after  it  has  made  the  picture  appear 
too  serious. 

Strenuous  measures,  like  hydrotherapeutic  treatments,  especially 
thermal  cures,  are  naturally  to  be  avoided.  To  prevent  apoplexy  in 
pronounced  arteriosclerosis,  everything  is  to  be  excluded  that  increases 
the  blood  pressure  or  leads  to  a  rush  of  blood  to  the  head,  especially 
hot  baths,  excessive  eating  and  drinking,  etc.  Experience  shows  that 
a  cerebral  hemorrhage  is  occasionally  connected  with  such  influences; 
but  too  much  cannot  be  expected  from  these  regulations. 

In  arteriosclerotic  epilepsy  besides  bromides,  iodide  may  also  be 
given.    But  it  is  usually  an  incurable  disease. 

In  accidents  following  sudden  cerebral  diseases  the  family  physi- 
cian's most  important  psychiatric  problem  often  is  to  obtain  a  clear 
idea  of  the  patient's  mental  condition;  because  he  sometimes  has  to 
decide  his  testimentary  ability  either  for  present  purposes  or  later  in 
court  as  expert  or  witness.  Care  must  be  taken  not  to  mistake  aphasic 
or  paraphasic  symptoms  (including  paragraphia)  for  confusion  and 
dementia.  In  all  cases  where  it  would  be  a  question  as  to  the  patient's 
responsibility  for  his  actions  pains  should  be  taken  to  get  in  contact 
with  the  patient  through  the  most  various  means  of  understanding. 
Since  wills  frequently  are  attacked  only  after  years  have  elapsed,  pains 
must  not  be  spared  to  make  exact  notes  of  the  case. 

Senile  Dementia  (Simple  Dementia  Senilis) 

Even  though  the  normal  regression  of  the  brain  begins  in  the  early 
fifties,  it  does  not  usually  become  plainly  noticeable  until  the  last 
decade  of  the  normal  span  of  life.  The  earliest  sign  we  meet  with  in 
most  cases — in  many  people  even  before  the  end  of  the  sixth  decade — - 
is  a  certain  inability  to  assimilate  the  new  ideas  of  others.  Such  per- 
sons become  passively  neophobic  even  though  they  are  still  capable 
themselves  of  creating  new  combinations  of  ideas  to  a  limited  extent. 
But  after  a  while  the  entire  ability  to  assimilate  is  weakened;  the 
old  man  is  less  and  less  interested  in  what  goes  on  in  the  world;  his 
thoughts,  now  egocentric,  are  withdrawn  to  the  more  personal  necessi- 
ties, both  in  emotional  and  intellectual  relations.  The  feelings  become 
more  labile,  and  react  to  trifles;  more  protracted  moods  readily  occur. 
In  social  intercourse  some  cases  show  a  tendency  to  empty  chatter, 
others  to  torpid  monosyllabism.    Besides  excessive  suggestibility  one 


THE  INDIVIDUAL  MENTAL  DISEASES  287 

is  struck  by  a  stubborn  intractablcness.  Not  only  the  impressibility 
but  the  entire  memory  becomes  poorer,  at  first  for  names  and  similar 
efforts  which  are  otherwise  also  particularly  difficult.  The  inability 
to  understand  and  recall  new  experiences,  the  relatively  or  absolutely 
easier  reproduction  of  the  old  memory  material  in  connection  with  the 
general  trait  that  memory  pictures  of  a  pleasant  character  can  be  more 
readily  revived  than  the  unpleasant,  makes  them  into  laudatores  tem- 
poris  acti.  All  psychic  processes  become  more  trying  and  slower,  par- 
ticularly in  proportion  to  their  complexity.  That  the  capacity  for 
practical  work  declines  under  these  conditions  is  self-evident. 

Simple  senile  dementia  is  said  to  be  a  simple  exaggeration  of  these 
symptoms  which  in  a  mildly  indicated  or  pronounced  form  are  found 
in  nearly  every  person  who  attains  his  normal  end  through  "weakness 
of  old  age." 

As  the  first  morbid  symptom  there  is  often  noticed  a  change  of 
character,  sometimes  at  first  in  the  sense  of  caricaturing  personal 
peculiarities;  a  sense  of  order  develops  into  picayune  pedantr}',  firmness 
into  stupid  stubbornness,  care  into  distrust,  economy  into  filthy  stingi- 
ness. Then  as  in  paresis  there  comes  the  falsely  so-called  ethical 
obtuseness  which  here  also  is  a  combined  product  of  imperfect  concep- 
tion and  elaboration  of  experiences  and  ideas ;  and  perhaps  at  the  same 
time  there  appears  the  lability  of  the  affectivity  with  its  heightened 
negative  and  positive  suggestibility:  "The  old  man  is  a  child."  The 
beginning  of  the  disease  is  sometimes  marked  by  sexual  excitation. 
Men,  who  have  long  been  impotent,  "feel  young  again"  and  under 
certain  conditions  actually  perpetrate  excesses.  Others  remain  more  or 
less  impotent  but  the  libido  is  enhanced. 

Then  the  memory  fails  more  and  more  and  just  in  simple  senile 
dementia  this  often  occurs  in  an  entirely  systematic  manner;  the  more 
recent  an  experience,  the  sooner  it  is  forgotten;  (usually  it  is  still 
"noticed";  but  is  capable  of  being  recalled  only  for  a  short  time).  At 
first  single  experiences  of  the  immediate  past,  which  naturally  is  also 
the  period  of  disease,  are  irregularly  forgotten;  these  gaps  increase 
slowly  and  with  fluctuations;  they  coalesce  until  the  last  years  disap- 
pear from  the  memory  at  first  in  part,  then  entirely.  Then  in  the 
course  of  years  the  limits  of  recollection  are  pushed  back  farther  and 
farther  and  at  last  the  patients  live  only  in  their  childhood.  An  old 
woman,  who  in  the  ninety  years  of  her  life  had  changed  her  residence 
several  times,  at  first  believed  herself  in  her  last  residence,  then  in  the 
next  to  last,  etc.,  until  at  last  she  returned  to  her  birthplace.  Another 
patient  was  just  coming  from  school.  It  is  very  common  for  senile 
women  to  give  their  maiden  names,  to  believe  that  they  have  just 


288  TEXTBOOK  OF  PSYCHIATRY 

recently  been  confirmed  and  to  have  no  recollection  of  their  marriage 
and  their  entire  adult  life.  The  most  important  events,  such  as  the 
husband's  death,  etc.,  can  be  told  to  the  patient  in  this  stage  several 
times  within  a  few  minutes  and  they  always  conceive  the  information 
as  something  new  with  the  corresponding  emotional  reaction;  they 
themselves  are  untiring  in  recounting  the  same  news;  in  severe  cases 
they  not  only  do  not  know  what  they  experienced  the  day  before,  but 
under  certain  circumstances  forget  everything  from  one  minute  to 
another.  Sometimes,  however,  experiences  that  intimately  concern  the 
personal  complexes  are  retained  like  memory  isles;  it  may  be  an  unjust 
accusation  or  an  attempt  to  obtain  money  from  a  stingy  old  man,  etc. 
As  in  paresis  practiced  streams  of  thoughts  also  are  sometimes  still 
capable  of  relatively  good  reproductions. 

Lively  natures  fill  up  the  memory  gap  with  spontaneous  confabula- 
tions, they  tell  fantastic  stories  of  what  they  have  accomplished  and 
experienced;  in  torpid  natures  the  symptom  has  to  be  provoked  by 
questions.  Many  of  these  people  do  not  like  to  say  "I  do  not  know" 
and  produce  an  answer  invented  for  the  occasion  which  they  themselves 
believe. 

The  range  of  ideas  is  markedly  restricted,  even  though  the  lack  of 
critical  ability  rarely,  and  then  much  later  reaches  the  high  degree 
as  in  paresis. 

In  the  first  years  the  patients  usually  try  to  act  as  usual;  only 
torpid  and  depressive  cases  give  up  the  active  relations  with  the 
environment.  But  then  actions  become  clumsy,  unsteady  and  finally 
entirely  senseless.  Because  of  their  lack  of  -thoughtfulness  they  permit 
themselves  to  be  misled  into  stupid  financial  transactions  and  uncalled 
for  gifts  and  bequests.  Seniles  are  favorable  material  for  legacy 
hunters  not  only  because  they  will  die  soon  but  especially  because  they 
are  helpless  against  clever  external  influences.  The  attempt  to  obtain 
the  fortune  is  frequently  made  by  way  of  marriage  in  which  case  the 
heightened  sexuality  in  many  patients  offers  a  good  opportunity.  In 
a  great  many  cases  the  external  forms  are  retained  for  a  long  time. 
A  woman  entirely  unknown  to  me,  about  whom  I  was  consulted,  re- 
ceived me  as  a  female  acquaintance  (although  she  could  see  very  well) ; 
she  entered  into  a  conversation  with  me  in  the  usual  social  phrases 
without  making  a  single  slip,  aside  from  the  fundamental  fiction,  she 
asked  what  my  children  were  doing,  said  that  it  pleased  her  that  I 
had  at  last  come  again,  and  remarked  that  it  was  cold  but  pleasant 
weather,  etc. 

Some  do  not  feel  comfortable  anywhere,  especially  at  night.  With- 
out purpose,  or  with  unclear  ideas,  or  to  look  after  their  things,  they 


THE  INDIVIDUAI.  MENTAL  DISEASES  289 

wander  about  the  house  spook-like  with  u  li^ht  and  consequently  often 
become  dangerous.  In  the  hist  stage  real  deliria  are  usually  added, 
especially  those  occurring  at  night;  the  patients  then  live  in  hallucina- 
tions of  experiences  of  youth  but  also  in  other  adventurous  and,  usually 
in  emotionally  accentuated  phantasies. 

Perception  and  attention  are  gradually  changed  in  the  sense  of  the 
organic  disturbance. 

Orientation  is  disturbed  rather  late,  often  at  first  transiently  at 
night,  then  also  during  the  day.  The  patients  no  longer  know  what 
year  it  is,  often  not  even  the  century,  and  when  the  year  has  been 
told  them  they  are  not  capable  of  reckoning  their  age,  usually  state  it 
incorrectly,  even  when  they  know  the  year  of  their  birth,  as  they  often 
do.  They  can  mistake  day  and  night  though  in  the  nightly  excitations 
they  want  to  go  to  their  customary  daily  occupation  more  frequently 
than  they  mistake  the  day  for  the  night.  Sometimes  they  themselves 
feel  that  they  are  in  a  confused  condition;  one  of  our  patients  has 
maintained  for  two  years  that  she  is  at  home  and  sleeping,  and  that 
her  being  here  and  everything  she  experiences  here  is  only  a  dream. 

In  the  last  stage  disorientation  also  affects  the  simplest  situation. 
Then  it  is  particularly  characteristic  that  anxious  senile  patients,  when 
they  have  to  be  lifted  or  carried,  grab  hold  everywhere  of  people  and 
doors  and  every  object  that  they  can  reach,  wherebj'  they  naturally 
increase  the  danger  of  falling. 

The  large  majority  of  seniles  have  only  these  basic  symptoms;  it  is 
a  case  of  simple  senile  dementia  analogous  to  simple  paresis  and  simple 
demented  schizophrenia.  But  these  people  rarely  come  to  the  insane 
asylums;  their  death  is  awaited  in  their  families  and  in  the  poorhouses. 

But  various  accessory  symptoms  can  change  the  picture  and  often 
make  institutional  care  necessary.  Even  among  the  simple  senile  cases 
some  are  more  torpid,  others  more  lively.  The  torpidity  can  increase 
to  stupor,  the  liveliness  to  an  erethism  in  which  the  patients  who  are 
in  continuous  activity  combined  with  a  talking  mania  can  hardly  be 
made  to  rest.  The  mild  affective  displacements  which  are  frequent 
in  old  age  can  rise  to  melancholic  and  manic  conditions,  of  which  the 
first  are  very  frequent,  the  second  rather  rare  {senile  melancholia  and 
mania) .  The  depression  is  frequently  accompanied  by  anxiety  though 
perhaps  less  often  than  in  the  arteriosclerotic  forms. 

In  such  affective  conditions  delusions  are  invariably  formed,  and 
depending  on  the  mental  state  they  are  either  delusions  of  insignificance 
or  greatness.  The  latter  is  always  very  weak  and  does  not  attain  the 
multi-colored  and  fantastic  magnitude  of  the  paretic  delusion.  In  the 
depressive  delusional  forms  the  delusion  of  poverty  usually  recedes 


290  TEXTBOOK  OF  PSYCHIATRY 

before  the  horribly  developed  delusions  of  sin  and  hypochondriasis. 
These  are  often  accompanied  by  nihilistic  ideas  and  ideas  of  enormity, 
which  are  specific  in  organic  diseases,  and  occasionally  also  by  micro- 
manic ideas,  the  patients  believing  themselves  or  some  parts  of  their 
bodies  to  be  very  small,  which  gives  them  occasion  for  anxiety  and 
justification  of  the  anxiety.  The  mere  poverty  of  ideas  is  shown  in 
the  following  complaint;  "I  must  make  so  much  water;  the  nurse  will 
not  empty  the  chamber;  what  will  happen?  I  have  such  parched  feel- 
ing and  what  if  the  nurse  will  not  give  me  any  water?  And  when  this 
jacket  is  dirty,  then  they  will  send  me  one  that  is  too  thin." 

Very  often  these  affective  delusions  are  mingled  with  delusions  of 
suspicion,  self-reference  and  of  persecution;  the  delusion  of  being 
robbed  is  something  quite  common  in  senile  diseases. 

Even  in  otherwise  simple  forms  delirious  conditions  with  hallucina- 
tions occur  in  the  final  stage.  Individual  hallucinations  may  now  and 
then  be  noticed  earlier;  it  is  generally  a  case  of  auditory  and  also  visual 
hallucinations.  Hallucinations  of  smell  and  taste  are  rare.  The 
patients  see  and  hear  dreamlike  transactions ;  for  instance,  they  live  in 
a  previous  activity,  or  like  presbyophrenics,  they  busy  themselves  with 
mixing  everything  up,  packing  their  beds  and  all  their  things  together, 
in  order  to  go  "home,"  etc.  The  term  "occupational  delirium"  is  also 
used  in  this  connection,  but  in  the  forms  of  senile  dementia  not  com- 
plicated with  alcoholism  the  picture  is  entirely  different  from  that  in 
delirium  tremens.  In  the  latter  there  is  an  uncertain  complicated 
pseudo-activity  in  individual,  not  really  connected  parts.  The  patients 
believe  that  they  are  sitting  in  a  bar-room,  that  they  are  writing, 
driving,  while  they  may  be  lying  on  their  backs  in  bed,  or  if  they  are 
walking  about  they  do  notice  that  something  is  wrong,  whereas  in 
the  senile  patients,  it  concerns  mostly  real  acts,  even  if  they  appear 
decidedly  purposeless.^^  Many,  even  those  who  are  relatively  clear, 
collect  useless  rubbish,  they  go  to  the  street  to  look  for  things  that 
the  children  have  carried  away,  "they  look  for  something,  upset  the 
bed,  tear  open  the  mattress,  mix  up  the  horse  hair,  tear  up  the  linen, 
frequently  cover  themselves  with  it  in  a  phantastically  senseless 
manner"  (Fischer).  If  they  are  not  confined  to  the  bed  they  busy 
themselves  incessantly  with  something  that,  though  producing  little 
that  is  comprehensible,  always  pursues  some  idea.  It  is  only  with  the 
complete  decline,  that  the  stereotyped  movements  come  which  corre- 
spond to  the  previous  occupation  (washing  and  sewing  motions,  etc.) 
The  patients  then  often  become  unclean,  not  only  because  of  careless- 
ness and  paralysis,  if  not  carefully  watched  they  readily  begin  to 

"  Comp.  p.  237. 


THE  INDIVIDUAL  MENTAL  DISEASES  291 

play  with  the  excrements.  Such  conditions,  which  in  their  higher 
developments  must  be  designated  as  severe  deliria,  occur  at  first  most 
frequently  at  night  or  they  last,  as  transient  excitations,  for  days  and 
weeks,  or  finally,  near  the  end,  they  form  a  chronic  condition  that  may 
continue  for  months  and  years. 

Other  accessory  symptoms  result  from  local  disturbances  in  the 
brain  which  are  not  directly  a  part  of  the  disease  but  naturally  appear 
frequently  as  a  result  of  the  arteriosclerosis  that  exists  at  the  same 
time;  among  these  we  have  paralyses,  aphasic  and  apractic  disturb- 
ances. The  spinal  cord  is  usually  also  involved  more  or  less,  so  that 
the  sphincter  muscles  and  the  (lower)  extremities  also  are  no  longer 
controlled  properly. 


Fig.  9. — The  handwriting  of  a  simple  senile  dement  of  the  lighter  grade,  show- 
ing regular  tremors.    The  patient  took  great  pains  to  WTite  very  carefully. 

The  physical  symptoms  are  otherwise  chiefly  basic  symptoms  which 
correspond  with  the  general  cerebral  atrophy  among  which  we  find: 
clumsiness,  stiff  weak  motions,  and  finally  marasmus.  INIetabolism  is 
retarded  very  early,  the  appetite  frequently  disappears,  the  hand- 
writing becomes  shaky  and  in  many  cases  is  clumsy  in  other  respects. 
Sometimes  the  tremor  is  entirely  regular  but  rather  coarse.  Other 
manifestations,  as  the  shrinking  and  the  decrease  in  the  elasticity  of 
the  skin,  the  arco  senilis  in  the  cornea,  etc.,  are  expressions  of  the 
general  decrease  in  vitality,  to  which  the  brain  atrophy  also  belongs; 
they  are,  therefore,  parallel  manifestations,  which  in  relation  to  the 
brain  disturbance  may  be  developed  to  very  different  degrees. 

On  the  basis  of  these  accessory  symptoms  different  forms  have  been 
distinguished. 

If  there  are  no  accessory  symptoms  at  all,  we  have  senile  demejitia 
in  the  narrower  sense,  or  the  simple  form  of  dementia  senilis.  The  forms 
with   affective  displacements,   such   as  the  senile   melancholias   and 


292  TEXTBOOK  OF  PSYCHIATRY 

manias,  are  probably  the  commonest  among  the  institutional  cases. 
That  these  names  designate  only  the  acute  pictures  with  which  the 
patient  usually  comes  to  the  physician,  need  not  be  so  important, 
because  as  indicated,  the  moods  are  usually  still  recognizable  in  the 
quiet  period  also. 

The  forms  showing  a  clear  sensorium  with  delusional  formation 
and  eventually  hallucinations  are  designated  as  senile  paranoia  (or 
paranoid  forms  of  dementia  senilis) ;  they  are  not  frequent.  Such 
people  think  they  are  spied  on  by  neighbors,  teased,  robbed  especially 
by  those  living  in  the  same  house,  they  find  everywhere  references  to 
themselves,  and  confirmation  of  their  ideas  in  voices,  etc. 

In  dementia  senilis,  as  in  paresis,  catatonic-like  forms  have  been 
spoken  of,  inasmuch  as  one  observes  stereotype  movements  and  atti- 
tudes, verbigeration,  flexibilitas  cerea,  stupor,  and  echolalia.  Many  of 
these  cases,  as  the  anamnesis  and  other  symptoms  show,  are  undoubt- 
edly (latent)  schizophrenics  that  have  become  senile.  In  others  the 
stereotype  movements  prove  to  be  remnants  of  habituated  movements 
(twisting  the  moustache,  scratching).  What  gives  the  impression  of 
verbigeration  is  often  plainly  nothing  but  the  incessant  expression  of 
the  identical  feeling  that  always  dominates  the  patient,  as  in  such  an 
expression  as  ''Oh,  God,  help  me!"  or  it  represents  an  organic  preserva- 
tion in  which  the  patients  want  to  say  something  else  but  invariably 
slip  back  into  the  once  trodden  path.  The  echolalia  may  be  an  organic 
disturbance  which  is  probably  somewhat  differently  conditioned  than 
in  schizophrenia.  But  as  yet  we  do  not  know  enough,  and  can  only 
insufficiently  analyze  these  invariably  severely  demented  patients,  in 
order  to  make  an  exact  differentiation  in  the  individual  case  between 
schizophrenic  and  organic-catatonic  symptoms.^^ 

The  course  of  simple  dementia  senilis  is  usually  very  slow;  it  may 
extend  over  a  decade.  The  weakness  sets  in  very  gradually;  not  even 
the  year  in  which  senility  merges  into  disease  can  be  regularly  deter- 
mined. With  minor  fluctuations  the  dementia  and  the  physical  weak- 
ness gradually  increase;  extensive  remissions  are  not  to  be  expected 
here. 

Also  the  paranoid  forms  with  complete  clearness  usually  run  a 
decidedly  chronic  course,  but  the  delusions  are  subjected  to  some- 
what severer  and  more  frequent  fluctuations,  so  that  really  bearable 
conditions  can  sometimes  alternate  with  those  that  are  almost 
delirious. 

Acute  shifts  with  total  confusion  can  appear  very  early  and  under 
certain  conditions  can  disappear  after  a  few  weeks  or  months,  so  that 

"^  Compare  p.  236. 


THE  INDIVIDUAL  MENTAL  DISEASES 


293 


Wernicke  e.g.,  may  talk  of  cures.  But  even  if  the  patients  do  not  die 
soon,  new  and  definitive  exacerbations  are  to  be  expected. 

Senile  manias  and  melancholias  can  heal,  the  manias  very  often, 
the  melancholias  less  frequently.  But  many  of  the  latter  are  also 
disposed  to  gradual  improvement.  However,  the  senile  dementia  then 
remains,  even  though  it  is  often  noticeably  of  slight  force.  But  as  in 
paresis  the  affective  forms  tend  to  a  lasting  displacement  of  the  affects, 
since  after  the  storm  has  run  its  course  a  milder  euphoric  or  depressive 
mood  remains.  Senile  melancholia  can  even  maintain  itself  for  years, 
up  to  death,  on  the  same  plane  of  melancholic  depression. 

Anatomically  senile  dementia  proves 
to  be  a  diffuse  reduction  of  the  entire 
central  nervous  system.  As  in  paresis 
the  convolutions  are  narrowed,  uneven 
at  the  surface,  the  ventricles  are  wid- 
ened, at  death  the  entire  brain  is  re- 
duced just  as  much  as  in  arterio- 
sclerosis. 

The  pia  is  clouded  but  hardly 
really  opaque,  just  as  little  is  it  in- 
filtrated. 

The  ganglion  cells  disappear  in 
different  ways.  They  dissolve,  they 
undergo  fatty  or  pigmentary  degenera- 
tion, and  vacuoles  are  formed  in  them. 
The  glia  hypertrophies,  but  more  as  to 
the  number  of  the  elements  than  in 
thickness  of  the  fibres  or  in  size  of  the 

cells ;  in  contrast  with  paresis  the  cells  usually  remain  relatively  small 
and  delicate,  and  the  fibres  remain  thin;  mitoses  are  rarely  seen  (except 
in  acute  lesions).  In  addition,  debris  and  products  of  cells  are  natu- 
rally found. 

The  causes  of  senile  dementia  are  still  quite  obscure;  undoubtedly 
the  hereditary  disposition  plays  a  part.  The  maximum  of  the  disease 
lies  in  the  age  between  sixty-five  and  eighty  years.  The  disease  afflicts 
both  sexes  about  equally. 

Early  waning  of  the  trophic  energy  of  the  brain  occurs  especially 
in  oligophrenics  (sometimes  as  early  as  in  the  forties),  in  akoholics 
("Dementia  alcoholica  senilis,"  Ford,  with  transition  to  chronic 
Korsakoff  of  earlier  age),  in  manic  depressives,  and  in  endocardiacs. 

Not  rarely  acute  debilitating  diseases,  like  pleuritis,  or  fracture  of 
the  neck  of  the  femur,  etc.,  occasion  the  outbreak. 


Fig.  10. — Pyramidal  cell  in  a 
simple  dementia  senilis.  The  well 
preserved  fibrils  (clearer  in  the 
specimen)  form  a  net  about  the 
fat  droplets  that  fill  up  and  bulge 
out  a  part  of  the  cell. 


294  TEXTBOOK  OF  PSYCHIATRY 

Dijferential  Diagnosis.  The  most  difficult  thing  in  the  diagnosis  is 
to  differentiate  it  from  "normal"  senility.  Where  the  line  should  be 
drawn  is  arbitrary.  For  forensic  purposes  one  must  depend  on  the 
practical  considerations;  all  things  being  equal,  a  wholesale  merchant 
should  be  declared  insane  and  incompetent  even  if  he  shows  less  severe 
disturbances  than  a  day  laborer  in  the  same  state.  Indeed,  under  rare 
circumstances  a  few  harmless  delusions  will  not  yet  induce  us  to  declare 
the  patient  practically  as  mentally  unsound,  while  naturally  in  the 
medical  sense  all  such  cases  are  pathological  in  the  same  way  as  those 
showing  a  noticeable  affective  displacement. 

The  disease  is  distinguished  from  arteriosclerotic  insanity  by  the 
absence  of  arteriosclerotic  and  local  manifestations,  by  the  more  gen- 
eral affection  of  all  functions,  and  the  greater  steadiness  of  the  course. 
But  the  frequency  of  the  combination  of  both  diseases  may  cause 
difficulties  which  are  fortunately  chiefly  of  a  theoretic  character  only. 

The  melancholic  and  manic  states  are  recognized  as  senile  by  the 
organic  signs  of  the  disease,  the  lability  of  the  affects,  and  the  sense- 
lessness of  the  delusions,  etc.  The  weakness  of  the  memory  is  sometimes 
revealed  by  the  fact  that  the  affects  exert  an  abnormal  influence  over 
it.  Thus  a  melancholic  patient  in  the  incipient  stage  of  senility,  whose 
memory  otherwise  appears  to  be  still  completely  intact  and  who  is  also 
still  capable  of  work  to  a  considerable  extent,  may  be  noticed  by  the 
fact  that  he  forgets  (it  is  not  a  blocking)  all  pleasant  experiences, 
while  he  retains  very  well  all  those  that  correspond  with  his  mood. 

Treatment:  For  the  prophylaxis  of  senile  dementia  we  know  noth- 
ing that  can  be  done  except  to  avoid  all  the  ordinary  nervous  injuries, 
above  all  alcohol.  Besides  the  physician  must  be  careful  not  to  create 
situations  that  may  act  as  causes.  Old  people  suffering  from  a  fracture 
of  the  neck  of  the  femur,  whenever  possible,  should  not  be  long  confined 
to  the  bed,  etc. 

When  the  disease  has  once  broken  out  it  naturally  cannot  be  cured. 
The  general  principles  of  therapy  in  the  senile  psychoses  should  be 
symptomatic. 2* 

Presbyophrenia 

Presbyophrenia,  the  classification  of  which  to  be  sure  varies  accord- 
ing to  the  author  and  even  in  the  same  author  at  different  times,  is, 
according  to  some,  a  special  morbid  picture,  according  to  others  a 
variation  of  dementia  senilis.  According  to  the  present  state  of  the 
question,  a  morbid  picture  is  best  called  presbyophrenia  which  in  its 
typical  cases  is  very^  well  characterized.    It  always  presents  the  general 

"  Sec  p.  279. 


THE  INDIVIDUAT.  MENTAL  DISEASES 


295 


signs  of  dementia  senilis,  but  shows  Ijcsidcs  a  peculiar  excitation  and 
an  alteration  of  thinking  that  extends  beyond  the  ordinary  senile  dis- 
turbance. The  patients  are  always  engaged  in  an  apparent  activity; 
as  long  as  they  walk  and  can  orient  themselves  at  least  in  their  im- 
mediate surroundings,  they  fuss  about  incessantly,  things  are  mis- 
placed, carried  to  another  place,  everywhere  something  is  looked  for, 
and  all  of  this,  without  anything  being  really  accomplished.  If  the 
patients  are  weaker,  they  cannot  lie  in  bed  decently ;  even  there  they 
are  occupied,  they  sit  in  any  old  way,  and  stretch  their  legs  out  of  bed. 
With  uncertain  but  eager  motions  the  bed  clothes  are  pulled  together, 
twisted  together,  tied  into  disorderly  bundles  or  only  moved  and 
rubbed  together  (the  patient  "is 
washing") .  Despite  a  good  affective 
rapport  with  the  surroundings,  per- 
sons, places,  situations,  and  times 
of  day  are  mixed  up,  just  as  much 
as  the  bedding.  As  long  as  the  pa- 
tients can  talk  there  is  a  certain 
talkativeness,  behind  which,  how- 
ever, there  is  no  flight  of  ideas  un- 
less something  manic  exceptionally 
supervenes;  at  all  events  they 
readily  lose  the  thread  merely  be- 
cause of  weakness  of  memory.  For 
the  most  part  they  get  a  special 
kind  of  speech  disturbance  in  which 
at  times  they  no  longer  find  the 
words,  or  misplace,  repeat,  and 
mutilate  them,  and  cling  to  single 
syllables  that  either  do  or  do  not 
belong  to  the  word,  and  produce  alliterations  and  permutations,  as  well 
as  logoclonus,  etc.,  but  at  the  same  time,  at  least  in  the  beginning  and 
when  stimulated,  they  give  entirely  correct  answers. 

An  example  cited  by  Fischer'-^  illustrates  this  best:  ''iMother  of 
God,  Virgin  Mary,  our  lord,  our  dord  thour  dord,  dord,  dord  dord, 
de — de — de — de — Oh  now  just  listen,  blessed  fruit  of  the  body,  give  us 
this  day  your  our  ours,  holy  Mary  pray  for  usars,  so  that  we  much. 
.  .  .  Our  Lord  our  dord  so  that  we  shall  do  much.  Come  you  lousy 
fellow  come  quly,  dosoorly  sanctify  our  lord,  you  lousy  fellow,  than 
art  among  women,  the  fruit  of  the  body,  Jesus  well  yes,  that  is  the  great 

^'Ein    Beitrag    zur    Klinik    imd    Pathologie    der    presbyophrenen    Demenz. 
Zeitsch.  f.  d.  ges.  Neur.  u.  Psych.  Bd.  12,  1912,  p.  125. 


Fig.  11. — "Washing"  presbyophre- 
aic.  In  spite  of  the  demented  ex- 
pression one  can  see  the  eagerness 
in  the  activity.  Unfortunately  the 
resuhs  of  the  occupation,  the  dis- 
order of  the  bed,  are  not  visible  in 
the  picture. 


296  TEXTBOOK  OF  PSYCHIATRY 

one,  but  thou  thinkesest  holiest  our  Lord,  our  lord,  then  and  here  is 
certainly  certainly  sanctified  himself  himself,  but  thou  felt  for  the 
sinners  and  have  sanctifieth  all  sins  and  misdeeds  our  lord,  our  lord  has 
made  forbad  and  fruit  of  the  body  well  he  has  give  it  ever.  .  .  ," 

Typical  epileptiform  attacks  are  not  rare  in  presbyophrenia.  Hal- 
lucinations and  delusions,  concerning  which  more  exact  information  is 
naturally  not  easily  obtainable  frequently  exist,  but  are  not  at  all 
necessarily  as  a  determinant  for  these  peculiar  confusions. 

In  the  cases  thus  classified  one  finds  in  the  brain  regularly,  and 
in  especially  large  numbers,  the  senile  plaques  of  Fischer  (sphero- 
trichia),  the  significance  of  which  is  not  yet  clear.-''  In  the  other  forms 
they  rarely  occur,  so  that  the  morbid  picture  is  kept  together  even 
anatomically  to  a  certain  degree. 

Kahlbaum,  who  coined  the  name  presbyophrenia,  understood  it  to 
mean  senile  psychoses;  Wernicke  made  a  morbid  picture  of  it  which 
he  identified  symptomatologically  with  Korsakoff's  disease  so  that  the 
conception  corresponds  approximately  to  a  "simple  senile  dementia," 
the  torpid  forms  excepted.  Kraepelin  then  required  relative  retention 
of  the  order  of  the  mental  process  and  even  of  judgment,  without 
keeping  strictly  to  these  qualifications.  Fischer  found  somewhat  later 
in  his  anatomical  spherotrichia  a  definite  morbid  picture,  and  he  also 
put  the  disease  parallel  with  Korsakoff,  but  in  many  of  his  cases  it 
went  bej^ond  Korsakoff  in  the  far  greater  alterations  of  thinking,  and 
it  corresponded  in  part  with  the  one  pictured  above.  But  finally  pretty 
nearly  every  dementia  senilis  which  is  colored  to  a  considerable  extent 
by  accessory  symptoms  came  to  mean  for  him  presbyophrenic 
dementia,  thus  the  melancholic,  manic,  paranoid,  and  catatonic  forms 
(ever>i:hing  with  the  exception  of  his  "arteriosclerotic  pseudopresbyo- 
phrenic  dementia"),  which  correspond  practically  with  the  forms  of 
our  erethic  arteriosclerotic  insanity. 

Not  to  be  separated  from  presbyophrenia  for  the  present  is 
Alzheimer's  disease  in  which  one  deals  with  a  dementia,  beginning 
early,  in  the  sense  of  presbyophrenia,  but  which  in  a  few  years  leads 
to  a  particularly  high  degree  of  dementia  with  aphasic,  agnostic,  and 
apractic  symptoms  and  finally  results  in  death.  In  exceptional  cases 
it  may  break  out  in  the  forties.  The  anatomical  findings  correspond 
qualitatively  about  with  presbyophrenia  but  it  is  very  intensive;  there 
is  a  general  cerebral  degeneration  with  destruction  of  the  fibrils  and 
numerous  senile  plaques;  but  cases  are  also  included  in  which  the  one 
or  the  other  of  the  last  two  distinguishing  features  is  lacking. 

Course.    The   presbyophrenic    forms   usually   exhaust   themselves 

"See  below  anatomy. 


THE  INDIVIDUAL  MENTAL  DISEASES 


297 


within  one  or  two  years,  often  already  in  a  few  months  after  the  dis- 
ease has  become  manifest.  Tiie  more  acute  the  cases,  the  more  are 
fluctuations  to  be  expected;  many  of  the  slower  ones  run  an  entirely 
straight  course  until  death. 


Fig.  12. — Cortex  in  presbj'ophrenia.  a.  Cross  sections  of  large  senile  plaques, 
b.  Degenerated  fibrils  stuck  together,  c.  Fibrils  stuck  together  into  the  form  of  a 
fihng  as  the  remnant  of  ganglion  cell. 


Anatomically  besides  the  general  brain  atrophy  with  hypertrophy 
of  the  glia  the  senile  plaques  are  characteristic  {Fischer's  "Sphero- 
trichia,"  "senile  plaques,"  Simchowicz) .  Their  significance  as  yet  is 
in  no  way  clear.     Formations  are  involved  that  appear  threadlike  or 


298 


TEXTBOOK  OF  PSYCHIATRY 


Fig.  13. — Presbyophrenia.    Senile  plaques  in  the  brain  cortex. 


Fig.  14. — Presbyophrenia.    Senile  plaques.    More  strongly  magnified. 

roll  themselves  together  in  balls,  and  include  nervous  and  gliose  ele- 
ments in  a  trancformed  condition;  they  usually  form  conglomerates 
that  can  far  exceed  a  ganglion  cell  in  size  and  are  scattered  every- 
where in  the  brain. 


THE  INDIVIDUAL  MENTAL  DISEASES  209 

In  a  large  part  of  the  cases  with  senile  plaques  one  can  see  a  severe 
disease  condition  of  the  fibrils  which  is  not  visible  in  ordinary  senile 
dementia.  The  fibrils  bubble  up  and  drop  together  into  irregular 
forms.  Sometimes,  e.g.,  in  Alzheimer's  disease,  they  form  peculiar 
tangled  bundles. 

Differential  Diagnosis.    Pronounced  presbyophrenia  can  hardly  be 
mistaken.     It  is  often  compared  with  alcoholic  deliria.     In  part  the 
deliria  are  colored  in  that  way  by  accompanying  alcoholism.     In  most 
cases  it  is  purely  a  question  of  imperfect  differentiation.     Deliria  with 
hallucinations  of  sight  are  not  necessarily  alcoholic 
deliria.    For  this  diagnosis  all  or,  at  any  rate,  most 
of   the   symptoms  must   be   characteristic.     But 
above  all  the  state  of  consciousness  and  the  reac- 
tion rate  in  both  diseases  is  so  different,  that  usu- 
ally the  diagnosis  is  made  at  the  first  glance.    The 
alcoholic  can  be  roused  much  more  easily,  and  has 
a  quick  conception  and  rapid  reactions;  the  senile 
demented  rarely  gets  into  proper  touch  with  the 
environment  and  his  percejDtion  is  slow.    Perhaps 
the   good-natured  rapport   also,   which   is  rarely        -p      r_Xormil 
entirely  lacking  even  in  the  deeply  confused  senile     cortical  cell.  Stain- 
but  is  rare  in  the  confused  alcoholic,  can  be  utilized     ing  of  the  fibrils, 
in  the   diagnosis.     To   recognize   it   immediately 
one  must  have  seen  the  difference  between  the  presbyophrenic  eagerness 
for  occupation  and  the  alcoholic  occupation  delirium. 

Especially  the  slower  reaction  capacity,  the  mood,  and  frequently 
also  the  age,  distinguish  the  presbyophrenic  as  well  as  every  other 
senile  delirium  from  the  alcoholic  Korsakoff. 

The  causes  of  presbyophrenia  are  unknown. 

The  treatment  of  the  unyielding  disease  is  purely  symptomatic. 

VI.    THE   TOXIC   PSYCHOSES 

1.    The  Acute  Toxemias 

Among  the  acute  toxemias  Kraepelin  includes  Uremia  which  is 
important  inasmuch  as  epileptiform  attacks  occur  in  it,  and  because 
it  can  stimulate  any  cerebral  local  symptoms.  The  uremic  psychosis 
as  such  usually  runs  its  course  with  a  picture  of  various  deliria,  whose 
specific  peculiarities,  if  they  have  any  at  all,  are  not  yet  kno\s-n;  it 
proceeds  in  the  majority  of  cases  to  a  rather  sudden  death. 

Eclampsia  of  pregnancy  and  child  bearing  is  recognizable  by  epi- 


300  TEXTBOOK  OF  PSYCHIATRY 

leptiform  attacks,  besides  which  there  are  also  occasional  delirious 
conditions. 

In  carbon  monoxide  poisonings  after  the  patients  emerge  from 
the  narcosis,  they  may  run  their  course  with  a  picture  of  twilight  states 
lasting  for  hours  or  days.  Central  and  more  peripheral  paralytic  mani- 
festations often  complicate  the  disease.  If  the  patients  do  not  recover 
entirely,  then  the  organic  symptom  complex,  accompanied  usually  by 
conspicuous  severe  memory  defects  and  depression,  remain  as  an  ex- 
pression of  the  diffuse  destruction  of  the  brain  tissue.  Between  the 
first  toxic  sleep  and  the  later  developments  of  the  symptoms  several 
days  or  even  weeks,  free  from  disturbance,  may  intervene. 

Of  the  remaining  toxemias  we  unfortunately  have