COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX00033200 *■'• 'fi t ^.O? . Lis. CoUcgc of ^})ps(icians! anb burgeons! ILihvdivp MENTAL DISEASES MENTAL DISEASES A HANDBOOK DEALING WITH DIAGNOSIS AND CLASSIFICATION BY \¥ALTER VOSE GULICK, M.D. ASSISTANT SUPERINTENDENT WESTERN STATE HOSPITAL, FORT STEILACOOM, WASHINGTON ILLUSTRATED ST. LOUIS C. V. MOSBY COMPANY 1918 Copyright, 191S, By C. V. Mosby Company Press of C. V. Mosby Company St. Louis DEDICATED TO mi. WILLIAM NOBLE KELLER A TOKEN OF ESTEEM Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/mentaldiseaseshaOOguli PREFACE Recent readjustment in certain mental groupings and their nomenclature gives a special interest to those terms which are coming into common use. The short chapters put under this cover under- take a statement as to the data essential in the rec- ognition of the different psychoses. The forms of mental disease mentioned follow modern usage. The first chapter gives the classifi- cation now accepted for use in the War Department, and recommended for general adoption throughout the United States. However, the order of presentation belongs to the author, and is intended to put first those dis- orders that are most frequent, allowing the other divisions to be placed in suitable chapters. In this writing, aside from the direct observation of hospital patients, I have studied the subject as given in various texts, particularly those of Kraep- elin, Dercum, Tanzi, Diefendorf, White, and Jel- liffe. In access to hospital material, criticism, and val- uable suggestions, I have been very generously helped and here wish to thank those to whom I am 7 O PREFACE indebted, particularly Dr. W. N. Keller, Dr. Frank T. Wilt, Dr. A. C. Stewart, and Dr. Walter T. Williamson. W. V. G. Fort Steilacoom, Wash. INTRODUCTION This little book is no superfluity; born of the wants we all have for concise, digested information, it institutes a response to that need. Dr. Gulick felt the demand as others have, but he happily re- sponded. The physician in court, or conducting office or public examinations of the insane, or un- expectedly called upon for diagnosis in private practice, will accept this book with relief. It is original and pleasing, not a mere compilation, and has much pure Anglo-Saxon directness and clear- ness. It should be welcome to the profession. W. T. Williamson, M.D. Portland, Oregon. CONTENTS CHAPTER I PAGE Classification 17 CHAPTER II Definitions 22 CHAPTER III Examination 25 CHAPTER IV Manic Depressive Psychoses 30 CHAPTER V Dementia Precox 40 CHAPTER VI GeneraIj Paralysis 57 CHAPTER VII Paranoia 66 CHAPTER VIII Epileptic Psychoses 74 CHAPTER IX Organic DementIxV 79 CHAPTER X Involution Psychoses 96 11 12 CONTENTS CHAPTER XI PAGE Constitutional iNFEraorJTY and Defective Mental Develop- ment 105 CHAPTER XII Intoxication Psychoses Ill CHAPTER XIII Thyroigenous Psychoses 121 CHAPTER XIV Infection and Exhaustion Psychoses 125 CHAPTER XV Psychogenic Neurosis 130 CHAPTER XVI Constitutional Psychopathic States: Undiagnosed Psy- choses: Incidental Comments 134 CHAPTER XVII Shell Shock 137 ILLUSTRATIONS FIG. PAGE 1. Manic depressive insanity, manic tyiie 33 2. Manic depressive psychosis^ manic type 34 3. Manic depressive insanity 35 4. Manic depressive insanity, depressed type 37 5. Manic depressive insanity, depressed type 38 6. Dementia precox, hebephrenic type 41 7. Dementia precox, hebephrenic type 44 8. Dementia precox, hebephrenic type 40 9. Letters scratched on wall by a dementia precox .... 47 10. Dementia xjreeox, katatouic type 48 11. Dementia precox, katatonic type 49 12. Dementia precox, paranoid type 51 13. Dementia precox, paranoid type 52 14. Dementia xjrecox, paranoid type 53 15. Dementia precox, simple type 55 16. General paralysis, advanced second stage 60 17. General paralysis, advanced second stage 62 18. Paranoia 68 19. Paranoia 69 20. Paranoia 70 21. Epileptic insanity 77 22. Organic dementia, tabetic psychosis 85 23. Organic dem,entia, cerebral apoplexy 91 24. Organic dementia, cerebral trauma 93 25. Organic dementia, cerebral trauma 94 26. Involution psychosis, melancholia 97 27. Involution i^sychosis, melancholia 99 28. Involution psychosis, jiresenile delusional insanity . . . 101 29. Involution psychosis, senile dementia 103 13 14 ILLUSTRATIONS FIG. PAGE 30. Constitutional inferiority 106 31. Constitutional inferiority 107 32. Defective mental development, imbecility 108 33. Defective mental develoi)nient 109 34. Defective mental development 110 35. Intoxication i)sychosis, alcoholic hallucinatory dementia . 117 36. Thyrogenous psychosis, cretinism 123 MENTAL DISEASES MENTAL DISEASES CHAPTER I CLASSIFICATION The classification of mental diseases given below is the one adopted by the American Medico-Psycho- logical Association in May, 1917. This has been recommended for general adoption throughout the United States, and has been accepted for use in the War Department, under the direction of the Office of the Surgeon General. PSYCHOSES 1. Traumatic psychoses. 2. Senile psychoses. 3. Psychoses with cerebral arteriosclerosis. 4. General paralysis. 5.. Psychoses with cerebral syphilis. 6. Psychoses with Huntington's chorea. 7. Psychoses with brain tumor. 8. Psychoses with other brain or nervous dis- eases (specify when possible). 9. Alcoholic psychosis. (a) Pathologic intoxication. 17 18 MENTAL DISEASES (b) Delirium tremens. (c) Acute hallucinosis. (d) Korsakow's psychosis. (e) Chronic paranoid type. (f) Other types, acute or chronic. 10. Psychoses due to drugs and other exogenous toxins. (a) Morphine, cocaine, bromides, chloral, etc., alone or combined (to be specified). (b) Metals, as lead, arsenic, etc. (to be specified). (c) Cases (to be specified). (d) Other exogenous toxins (to be speci- fied). 11. Psychoses with pellagra. 12. Psychoses with other somatic diseases (spec- ify disease). 13. Manic depressive psychoses. (a) Manic type. (b) Depressive type. (c) Stupor. (d) Mixed type. (e) Circular type. 14. Involution melancholia. 15. Dementia precox. (a) Paranoid type. (b) Katatonic type. CLASSIFICATION 19 (c) Hebephrenic type. (d) Simple type. 16. Paranoia and paranoic conditions. 17. Psychoses with mental deficiency. 18. Psychoses with constitutional psychopathic in- feriority. 19. Epileptic psychoses. 20. Undiagnosed psychoses. IIsrEBRIETY Alcoholism. Drug addiction (specify drug). MENTAL DEFICIENCY Imbecile. Moron. Borderline condition. CONSTITUTIONAL PSYCHOPATHIC STATES Criminalism. Emotional instability. Inadequate personality. Nomadism. Paranoid personality. Pathologic liar. Sexual psychopathy. Other forms (specify). Undiagnosed. This classification is from a memorandum of the 20 MEHSTTAL DISEASES War Department that accompanied a letter sent by the office of the Surgeon General to the Superintend- ent of the Western State Hospital of Washington, under date of May 25, 1918, and is a part of the in- structions given under direction of the Surgeon Gen- eral to divisional psychiatrists and other medical officers in charge of neurological and psychiatric ex- aminations. For many years the reading, and even discussion, of nervous and mental diseases has been dif&cult, and inclined to apparent confusion of thought, be- cause of lack of uniformity in the meaning of words used. These difficulties have been emphasized by the period of development which has secured a standing for the manic depressive psychoses; has expanded the dementia precox group; limited the cases to be counted as true paranoia; and come to a more discriminating appreciation of various other forms. Further, the writers on these subjects have been in- dividualists, with opinions of their own concerning classification. The result has often been shown in court room disputes which concerned a definition more than a condition. All who read these subjects had to make adjustments between authors, and proper statistics have been impossible. The country is now indebted to the American Medico-Psvchological Association for shaping the CLASSIFICATION 21 present table, and this year cooperating with the Na- tional Committee for Mental Hygiene, to secure its introduction throughout the country and it is in place to add that the majority of the state hospitals have already either adopted this new system or indi- cated their intention to do so. CHAPTER II DEFINITIONS Insanity has no clean-cut and commonly accepted definition. This word goes back to a time when it was believed that sickness of the mind was all of one sort. Now there is a recognized group of sepa- rately defined mental diseases, and in Appleton's Medical Dictionary insanity is frankly called an "obsolete medical term." The word "psychosis," used in the plural, is acceptable and suggests fairly well the present attitude of this department of medi- cine which may regard certain mental conditions, paresis, dementia precox, paranoia and others, as in need of hospital care, just as general medicine may send to a hospital of another sort cases of typhoid fever, pneumonia or smallpox. The psychiatrist has no definition for his o^^ai use. Dercum provides for the court room the explanation of insanity as a "diseased state in which there is more or less persistent departure from the normal manner of thinking, acting and feeling," and Dr. W. A. White in a recent address has spoken of in- sanity as "a certain type of socially inefficient con- 22 DEFINITIONS 23 duct, a certain degree of socially inefficient conduct that causes trouble in the community." In law, procedures in connection with insanity have usually to do with the question as to whether an individual is in condition to properly care for himself and his property. Here also the word 'in- sanity" is loose in definition, and is further con- fused because of a lack of uniformity between dif- ferent states. The ground for commitment is found when there is a mental departure from the normal self of the individual of such duration and degree as to dis- qualify him, either on his own account or on account of others, from being a member of society. Common Symptoms of Diagnostic Value Ataxia indicates a lack of muscular coordination. Delusion is a false belief which can not be cor- rected by adequate evidence. Hallucination is a conscious sensation that comes without any external object to cause it. Thus the act of hearing when there is nothing to hear, or of seeing what does not exist (and is not even suggested by any object in sight) is a hallucination. Such an impression may come through any of the senses, but hallucinations of sight and hearing are most fre- quent. 24 MEXTAL DISEASES Illusion is a wrong interpretation of something that really exists. Orientation expresses the conscions relation of the individual to his environment and may concern it- self with place, time, and people. Pressure of activity indicates a mental state that demands expression in extraordinary muscle activ- ity and the dominant impulse is to movement on movement. Psycliomotor activity is the j)hrase describing muscle action under normal nervous control. When there is undue slo^^^less, psycliomotor retardation is a proper term, while the opposite condition is de- scribed as increased psycliomotor activity. Psychosis is a mental disease. CHAPTER III EXAMINATION The working out of a mental diagnosis may take much time and repeated observations, but with such an opportunity as is open to the physician when called to the home or the court room, usually he can reach some opinion as to the mental condition of the patient, so as to give advice as to the immedi- ate care needed and to comment as to the cause and outcome. Under such circumstances many processes of the laboratory or of a full clinical examination are either out of reach or for the time inexpedient, but because of the presence of friends and relatives it is ordinarily possible to get the advantage of a good history and this may mean much. At the court house it is the custom to follow the procedure of the commitment blank, while in the home the method must adapt itself so as to consider the patient and his family. An examination routine will lessen the risk of missing points that count. This is helped by a written memorandum, and especially in cases where 25 26 MENTAL DISEASES some legal opinion is asked a record of statements in the words of the patient may develop value. There are four general heads: (1) History of the family, (2) personal history of the patient, (3) his- tory of the disease, and (4) the present mental and physical condition of the patient. 1. General questions seldom get a family history. It is well to begin with the name, occupation and birthplace of the father and mother and the fact as to relationship between them; also to know the number of brothers and sisters, and then in re- gard to each of these, or any other near relative, to learn as to general health, deformities, nervous diseases, eiDilepsy, asylum commitment, mental pe- culiarity, known bad habits, use of alcohol, history of suicide or prison sentence. 2. The personal history may begin by asking as to incidents that marked the birth of the patient, having to do either with the mother or the child. Facts as to general health, diseases, injuries, and operations belonging to childhood or later life are to be recorded as well as information secured from such questions as were indicated in connection with the family history. Further, there is to be noted the years at school, the progress of the child as compared with others, then the developments that came later in his life at home and at work. In this connection, ability for physical and mental EXAMINATION 27 work, character development, habits in eating, forms of amusement, or the use of narcotics may- be of significance. Proi3er inquiry should be made as to emotional disturbance, which is particularly- liable to be evident at puberty and in connection with the menstrual periods. 3. In getting the history of the disease, a direct question may bring out the date of its beginning, but often this is unknown, for not infrequently the disease develops slowly and goes a long time with- out recognition. On this account, the date given may be wrong, indicating only the time when cer- tain symptoms forced attention. Sometimes the pa- tient can give for himself the most exact and accu- rate statement, but more often the story is best secured from his family. It is important to know whether there have been previous attacks, and if so Avhether or not the in- terval seemed to give a normal condition. The story of the onset and the subsequent symp- toms is sometimes told in a connected way, but more often it has to be asked for in a series of questions that may need to be repeated for different periods. For this the ground is well covered by the outline used by Diefendorf both here and in recording the mental status of the patient. This notes information as to hallucinations, illusions and delusions, and also as to disturbances in orientation, attention, memory ZQ MENTAL DISEASES and train of thought, as well as in the emotional and volitional fields. 4. In judging the present condition of the patient the physical examination, aside from the general findings of the chest and abdomen, should note the manner, attitude, degree of nourishment and any stigmata of degeneration, or evidence of cyanosis; also, the different reflexes, particularly the pupil- lary, should be observed. Information as to the mental state has been se- cured through the several stages of the examination, but is properly reviewed as to disturbance under the headings mentioned. Perception (hallucinations or illusions.) Apprehension (unconscious, befogged or dimin- ished sensibility). Attention (blunted, blocked, retarded, passive or easily distracted). Memory (impressibility faulty, retentiveness faulty, fabrication). Orientation (does the patient know where he is and who he is). Train of thought (paralysis of, retardation, com- pulsive, persistent ideas, flight of ideas, desultori- ness). Judgment (Are there delusions?). Emotional field (deterioration, irritability, seclu- siveness, fear, dejection, feeling of well being, sexual manif e stations ) . EXAMINATION 29 Volitional fidd (paralysis, retardation, hyporsug- gestibility, cerea flexibility, stereotypy, negativism, pressure of activity, mannerisms). In this way data can be obtained for a provisional diagnosis, though there will at times be occasion for later revision. Before ending this chapter mention is properly made of psychoanalysis, which is a procedure by which search is made for the elemental thoughts or incidents that lie at the beginning of the mental dis- turbance. This method properly carried out holds large possibilities, but in its nature and the time re- quired, goes beyond the limits of the type of exam- ination to which these pages belong. CHAPTER IV MANIC DEPEESSIVE PSYCHOSES Manic depressive insanity includes cases that used to be divided among different groups and named mania, melancholia, or circular insanity. Credit is given to Kraepelin for showing the en- tity of this psj^chosis. In mania and melancholia alike the patient continued free from progressive mental deterioration. Each ran through a period of mental disturbance followed by a relatively free interval with a later recurrence.. It was observed that in mania, depression might precede the state of excitement or follow as an interval shadow; while in melancholia the patient at times showed a varia- tion marked by some tendency towards excitement, and often this change of type was definite. Thus came the recognition of manic depressive insanity, which has a manic type, a depressed type, and a mixed type, and this mixed form, when alter- nation is direct mthout any interval, is called cir- cular insanity. There are no characteristic pathologic changes. The influence of heredity is not infrequently made 30 MANIC DEPRESSIVE PSYCHOSES 31 plain by the family history. A constitutional pre- disposition seems to yield before some circumstance of strain. It is not unusual to have the disease be- gin without any apparent cause. However, in these instances a full anamnesis may bring out both the hereditary taint and the nature of the circumstance that fixed the date of development. The manic type is divided into hypomania, acute mania and hyperacute mania. These forms place the degree of development. There are three impor- tant symptoms: flight of ideas, psychomotor excite- ment and emotional excitement. The ideas that come are normal in character, but each in turn tends to fail of being rounded out, because it is too quickly crowded aside by the next, which is soon lost in the one that follows. In the phrase '^flight of ideas" we have a figure that suggests thoughts coming in such a flock as to interfere with each other. Thus ideas come too close together to find space in time to unfold. But in hypomania this is not necessarily a marked symptom. Emotional excitement usually attracts attention and the patient may be nervous and quick, perhaps superficially clever. There is increased ac- tivity, which is inclined to change its direction and thus fail of any reasonable result. The individual act will be normal enough in character but liable to be broken off anywhere, and often there is uncalled 32 MENTAL DISEASES for irritability. As these incidents are prominently placed the work of the man is broken and his usual life made impossible. Acute mania emphasizes this picture, the flight of ideas attracts attention; an attempt at conversa- tion shows a medley of sentences and phrases, but between these there is usually connection, — that is, the one idea in some way calls the next; it may be similarity of sound or previous association, or a re- mote connection of any sort, that carries the patient rapidly on without apparent exhaustion. A flight of ideas stops ordinary observation, and in conse- quence the patient seems disoriented, to lack mem- ory and ability of apprehension, all to an extent that is beyond the fact. He can not keep still, and every impulse leads to action which now easily goes to violence. A manifestation of excitement is often the most striking s^^nptom, but this by itself is not enough to put the patient definitely in this group because dementia precox, general paresis, epileptic insanity, senile dementia and certain other psychoses may show periods of similar excitement, where the differential diagnosis requires other symptoms as well as the physical signs, which in certain cases are of most importance. Hallucinations and delusions can come, but are neither essential nor permanent. Occasionally there is a grotesque decoration of the person. Flight of MANIC DEPRESSIVE PSYCHOSES 33 Fig. 1. — Manic depressive insanity, manic type. 34 MEIs^TAL DISEASES ideas, psychomotor excitement and emotional ex- citement go on rather evenly. These three symp- toms increase for a certain period, which may be a Fig. 2. — Manic depressive psychosis, manic type, but here showing depressed state. week or more, reach a climax and then, gradually lessening, indicate the progress of a convalescence from this particular attack that may stretch tedi- ously through several months. The pulse is usually MANIC DEPRESSIVE PSYCHOSES 35 Fig. 3. — Manic depressive insanity, manic type. Ilair over face, hands in violent motion. 36 MENTAL DISEASES fast, pulse pressure low, knee jerks exaggerated, and the pupils equal. The hyperacute stage finds the patient exhausted from violence, incoherent, delusional, with conscious- ness clouded, and an emaciation complicated with toxemia. The depressed type also has three open symptoms : difficulty of thinking, psychomotor retardation, and emotional depression. The beginning often is marked by some situation that causes worry. Thus a painter and paper-hanger, subnormal in health from exposure to lead, when out of work for several months, brooded over the matter and could not sleep, had a poor appetite, sat around, attempted some work but could not carry it through. He left work undone without knowing why, hung paper upside down, and in other ways proved himself in- competent and was often unreasonable. This man was recently committed, but from this sequence we do not hold the lack of work as an adequate cause for what followed, though it was the incident of precipitation. Such a patient will often sit relaxed and apathetic, with folded hands and head bowed. It is hard for him to think and difficult to act. He lacks energy to begin, moves with hesitation, and if started can not finish anything. A man sent to help in caring for guinea pigs was weighed down by the thought MANIC DEPRESSIVE PSYCHOSES 37 Fig. 4. — Manic depressive insanity, depressed type. MENTAL DISEASES Fig. S. — Manic depressive insanity, depressed type. MANIC DEPIIESSIVE PSYCHOSES 39 of his responsibility. The degree of depression may be painful. Speech is an effort and the words are sometimes so indistinct that the sentence is easily lost. But patience in listening may prove the ability of the patient to remember and think correctly. Often there are feelings of self-condemnation, and delusions may go in this direction. The most fre- quent hallucination is that of smell, which is liable to be of some disagreeable sort. Physically the discomforts, as dizziness, palpita- tion, tinnitus and heavy limbs can be largely ex- plained through a faulty circulation. The weight may be subnormal, the blood pressure increased, and the pulse slow. Simple retardation, acute melan- cholia, and stuperous melancholia are divisions that indicate the degree of depression, the last of which is a befogged condition with the patient unable to respond to the processes of an examination. The diagnosis of the manic tj^pe from dementia precox, and of the depressed type from senile melan- cholia may take time. Here the essential informa- tion sometimes is obtained from a history that tells of relatively long lucid intervals, with different re- current attacks. This recurrence is characteristic of this disease; and with the diagnosis once made the prognosis expects another attack, though there may be an indefinite interval even of months reach- ing into years. CHAPTER V DEMENTIA PRECOX Dementia precox is perhaps the mental disorder that takes more young people to institutional care than any other. In Washington this gave over one- third of the total admittance for the last biennium. , It is a condition of mental deterioration. The cor- I tical cells show some degeneration and . the neu- roglia may be increased, but the pathologic find- _i^ ings are limited. The cause of this disease has not been established, but a rather generally accepted theory is that of an endogenous toxic effect, got pos- , sibly by the functional disturbance of a sex gland. .. However, some of the best recent work tends to find a psychogenic beginning, with a loss of balance in the mental metabolism. There are three main groups : the hebephrenic, the katatonic, and the paranoid, which have in com- mon certain fundamental markings. Where conver- sation is possible the examination usually develops a mental isolation that is characteristic, and makes the somewhat hidden background for other tj^Dical manifestations, as negativism and indifference. A 40 DEMENTIA PRECOX 41 muscular tension frequently emphasizes the nega- tivism, while the apparent indifference may show both in attitude and speech. The clinical picture has been called polymorphous, but these features, Fig. 6. — Dementia precox, hebephrenic type. mental isolation, negativism and indifference, are usually in some degree evident. Further, the orientation is persistently good; the patient knows who he is and where he is, though the examiner may be led astray as to his observa- 42 MENTAL DISEASES tion in a field that is controlled by some other symp- tom; and at the time of commitment it is rather usual for some degree of either excitement or stupor to be in evidence. From beginning to end the symptoms are such as may be developed through a mental deterioration, and it is this fact well held in mind that secures a fair understanding of the entity that gives to care- ful examination a group which allows more possi- bilities for individual variation than any other form of mental disease, and sometimes puts close together in diagnosis patients that show contrast in manner, speech and history. The intellect and the emotions have lost com- panionship; in consequence cause and effect may seem to have queer ly gone wrong ; the expression of pleasure may be clearly out of place; a silly laugh may go on as an uncontrolled physical performance. A broken pane of glass, or the loss of home and property are mentioned evenly with implied indif- ference. And this indifference which often is apparent is perhaps not so much a real indifference as it is a lack of observation, a perception which is too in- sufficient to either prompt action or thought. The beginning may be slow, characterized by indefinite or even misleading evidence. The child in some in- stances is precocious, but in time the tendency to DEMENTIA PRECOX 43 suioeriiciality grows ; cleverness proves a veneer only, and mental deterioration in some degree is under- neath, though in school, social life or business, this may for a while be well covered. The beginning is usually slow and even when the progress from the first open symptom leads to com- mitment quicker than is usual, in the light of what has happened there can be found suggestive color in the earlier history of the patient. Once developed, the disease often shows itself in mannerisms and repetitions of speech or action, and there may be an apparent looseness of thought for which psychoanalysis, where possible, can uncover the connection. Rarely an epileptiform convulsion occurs. 1. Of the three definite types, the hebephrenic is the most frequent form and its beginning is usually unrecognized. The dementia may show first sim- ply lack of ability to think and do well what might be normally expected, from this going on with a self- centered attitude to a marked carelessness in con- duct. Such a patient may brood or be irritable, be- come restless and irresponsible, develop some or all of the symptoms that have been mentioned as com- monly characteristic of this disease. Sexual passion may display itself. Hallucinations are liable to be of a disagreeable variety, and are most often of hearing, though bad smells and disturbing sights 44 MEI^TAL DISEASES are what the senses sometimes find. Delusions which are often of persecution, but may go in other direc- tions, are likely to be indefinite and shifting; and especially is it suggestive to have the patient give at Fig. 7. — Dementia precox, hebephrenic tj-pe. random outlandish or inadequate reasons as ex- planation of the delusions or for his conduct, and to be entirely satisfied. DEMENTIA PRECOX 45 An Italian writer has used the expression ^ ' stolid- ity of conduct," but for the hebephrenic type a dullness of emotion, with an irresponsible indiffer- ence, seems a closer comment in many cases. Physically the changes are such as might be ex- pected with a condition made subnormal in certain ways by the mental life. A low blood pressure is usual. A year ago a young man just of age, who had been firing on a small steamship, was judged insane. His commitment papers state that during the pre- ceding twelve months his actions and disposition changed radically, he refused to eat with others, used his hands only, became a glutton, had dirty habits, threatened people, swore, went for months without a bath and claimed that all kinds of perse- cution were being practiced against him. A report from the grandmother tells that the father was a drunkard. The patient as a little boy was likeable and bright in his studies, but this did not last; later he became impudent and lazy and neglectful of his appearance, the change being particularly evi- dent when he was about fourteen. With other findings the hospital examination ob- served the patient as stupid and confused, noted a diminished sensibility to external stimuli, clouding of consciousness, retardation of attention, desultory train of thought, psychomotor retardation, and al- 46 MEXTAL DISEASES I"ig. S. — Dementia precox, hebephrenic tj'pe. DEMENTIA PRECOX 47 ready knowing the history made a diagnosis of the hebephrenic form of dementia precox. Under hospital care, this young man improved physically and mentally, and within several months l)ecame an agreeable patient and good worker, de- livering supplies from the commissary. On March 21 of this year he was paroled into the care of his grandmother, but was returned in August as he became impudent, threatening and disagreea- ble in his habits. Fig. 9. — These letters were scratched on the wall by a dementia precox who did the same thing (with a nail) in a number of rooms. 2. Katatonia often displays very openly as its main symptom a stiffness of attitude supported by negativism and stupor. Some of these patients go to extreme length in resistance to everything and in maintenance of postures. The condition of stupor may change to one of excitement or, after lasting months, may in a short time make a marked improve- ment. Ten months ago an Austrian, twenty-two years old, was admitted. He was in bed and would hold 48 MENTAL DISEASES Fig. 10. — Dementia precox, katatonic type. DEMENTIA PRECOX 49 Fig. 11. — Dementia precox, katatonic type. 50 MENTAL DISEASES indefinitely the positions into which he was put, un- til lost through fatigue. He could be stood or moved as an automaton, and continued for months in this condition. Now he is up, able to walk, stands much of the time, is occasionally angry and then may bite, scratch or strike. Recently he put his hand through a window. Much of the time he stands in a charac- teristic katatonic attitude, but will now eat if left alone with food. 3. The paranoid type gives prominence to more or less fixed and progressive delusions, often of per- secution, together with other findings that show the patient a precox case. A delusion founded on some hallucination is fre- quent enough to be characteristic, but the connec- tion may be vague. A young man hears voices talk- ing, not to him, but so that he can overhear in part. He believes that the voices belong to some girl ac- quaintances, who are at the time on the roof and are calling on him to help because they are there being abused. For some the dementing process comes quickly, and then the delusions more easily go to absurdities and grotesque fancies. A musician, in his thirties, fills his conversation with a medley of delusions. He tells the story of a fight between two musicians as to whether violins or banjos are being used in China, and in close connection adds that the priesthood or- DEMENTIA PRECOX 51 ganizes on overcoats and sells overcoats. He states that the Bass Clef Society and the Weenie, Weenie Walker Club use different colors; that hymn 1098 Fig. 12.- — Dementia precox, paranoid type. was written in that year; that the color in his eye reveals to him that he sees snakes and has been fed 52 MENTAL DISEASES Fig. 13. — Dementia precox, paranoid type. DEMENTIA PRECOX 53 on snake eggs. He talks with Jim Hill indirectly and Mr. Hill pays musicians to study the Bible. More commonly the mental deterioration is slowly progressive, and the accompanying delusions occa- Fig. 14. — Dementia precox, paranoid type. This patient claims to be Presi- dent of the United States, Mayor of Seattle and Mayor of Tacoma, and wishes to be released so as to accept his official responsibilities. sionally persist through months with little or no change. Thus a young man committed by the Seattle court 54 MEXTAL DISEASES three years ago has continued his delusions of per- secution. His good physical condition and his straightforward, earnest manner easily hold atten- tion. He believes that he is illegally held and wishes to have this matter at once brought before the proper court, but with a chance to speak to the physician or anyone else, goes on to tell with detail how he is burned each night by electricity that comes from some machine outside the building. For some weeks he kept a diary which he wishes for court evidence, and this on each -page tells of the burning by electricity. Between this t^^^De of a delusion and those of paranoia there is similarity, but there is also an es- sential difference which is best measured in the ex- tent of stability that belongs to the one above the other. The delusion of a paranoiac holds with the firmness of an oak that grips solidly into the right ground with its root; while the delusion of the paranoid dementia precox is more like the California Yucca, which one easily uproots from its sandy soil. The dementia is the soil that prevents the same degree of fixity and systematization that charac- terize the delusions of paranoia. In addition to the three main types discussed a simple type is now recognized in diagnosis. This form is related to the hebephrenic, but the marks of dementia are not as distinctive. The beginning is DEMENTIA PRECOX 00 Fig. 15. — Dementia precox, simple type. Was a tramp, pockets were filled with rubbish. 56 MENTAL DISEASES of a gradual sort. Definite delusions and disagreea- ble hallucinations may work a period and then fade. Even simple responsibilities are not decently car- ried. Many prostitutes and tramps have belonged in this group. Recently men of this sort have passed through various recruiting offices into the army, where their conduct has usually got them into the guard house, from which they have been properly removed to institutional care or returned to their homes. No age line can be strictly placed, but it has been observed that cases in the hebephrenic group usu- ally begin when between fourteen and twenty years old, those of the katatonic t^^De in the third decade, and of the paranoid sort when over thirty. In dementia precox many cases reach some degree of improvement, but relatively few recover so as to stay apparently normal. For the paranoid type the prognosis as to recovery is bad. CHAPTER VI GENERAL PARALYSIS (Paresis; General Paresis; Dementia Paralytica) In an institution general paralysis is a rather well defined group, carried by organic changes in the brain through a characteristic course marked by progressive mental and physical deterioration, which in its last stage usually holds the patient bed- fast to a uniform end. For each of the several synonyms in the above heading there is good authority. General paralysis has the approval of present army usage. In the name dementia paralytica the words themselves are properly descriptive. Paresis is a shorter term that may come into general use, while general paresis is more accurate. General paralysis of the insane was the phrase with which Kraepelin first named the disease, and by some it is still preferred. Outside, the beginning comes without recognition; the date of the first symptoms is found later by ret- rospection. But an early diagnosis is of much con- sequence and may go far to save a family gross em- 57 58 MEXTAL DISEASES barrassment, and to hold the patient from business indiscretions of a serious sort. The pathologic findings for this disease are rich in detail, and taken as a group give a definite diag- nosis. The skull is often unevenly thickened, T^^ith the dura stuck fast in spots, while an effort to move the joia tears at points into the brain substance. The whole brain is somewhat shrunken, with fluid in the free spaces and evidence of inflammation going below the surface. Xerve fibers and cells show degenerative distortion; this is also true of blood vessels and hTuphatics. There is an increase in caiDillaries and often there are irregular dilata- tions and perivascular deposits. Lesions of an in- flammatory type mark the spinal cord, and there may be areas of softening. The cause of general paresis is now accepted as sj7)hilis, but the nature of the incident that brings this disease of the posttertiary stage to one and pro- tects ninety-nine others is unknown. The first evidence often comes as a character change. A man of respected standing may develop irregular habits that go any length in the disregard shown for custom or the ethics of society. Ability for api^lication is lost; indifference to detail is fol- lowed by an irresponsibility which can be partly hidden even while it is emphasized by an overac- tivity in attending to matters at hand. Emphasis GENERAL PARALYSIS 59 will often be put in the wrong place. A tendency to overlook important detail makes work unreliable ; carelessness usually shows in dress. All fine ma- nipulations are difficult, and the fingers grow awk- ward at knotting a tie. Lapses of memory go on to defects which may be repaired by the imagination; whatever enters the mind may come to be stated as a fact. Easily the patient lets go of money, grow- ing disinclined to work, and often for an outlandish act he gives an outlandish reason, with an apparent belief in its sufficiency. There is an expressed con- fidence as to immediate ability for doing large things. A man without money thus comes to talk of using millions in railroad construction, possibly to the moon. Delusions, while not essential to the picture, are usual, and when they come change easily and tend to absurdities, particularly as to wealth and power. Variation from a normal pupil can usually be found at some period in the disease, but is not al- ways permanent. The Argyll Eobertson reaction, or either an inequality or rigidity of the pupils is significant, and the consensual reflex may be lost. The knee jerks are most frequently normal or ex- aggerated, but may be lost. Further development is marked by the paretic seizure and, while this does not always come, it is especially a characteristic incident. Epileptiform 60 MENTAL DISEASES Fig. 16. — General paralysis, advanced second stage. GENERAL PARALYSIS 61 and apoplectiform are used as descriptive adjec- tives. This convulsion is at times indistinguishable from that of true epilepsy and can have as many variations, but is inclined to last longer and to clear less completely. Thus after every such attack the degree of dementia is deepened and, though after- wards improvement comes slowly, each time it fails to quite get back what was lost. Such a seizure, where there is no family history of mental disease, is suggestive. While there may have been earlier intervals when the symptoms could have been easily overlooked, the changes that follow take a more definite course. Already a loss of muscle tone has lessened facial expression, smoothed away wrinkles and caused the nostrils to spread. And also there has been some speech disturbance; a monotonous tone carries the words with lost accent, and the difficulty in articu- lation is brought out by test words as ' ' Seattle Post- Intelligencer. ' ' All these symptoms, as well as the other findings already named, grow more apparent. Speech, but writing more, loses syllables and leaves out words. The signature is sprawling and the address loses letters and becomes illegible. The Eomberg sign is usual and the gait ataxic. Finally the patient is put to bed because with growing weakness the unsteady gait has made it 62 MENTAL DISEASES Fig. 17. — General paralysis, advanced second stage. GENERAL PAnALVRTS 63 unsafe for him to walk. Then he lies bedridden for weeks or months, often unable to do anything for himself; only constant care may protect him from bed sores. Almost always there is appetite and good ability to eat. A feeling of well-being continues sel- dom broken, mental deterioration increases, conver- sation becomes impossible, but an occasional word suggests former delusions. It is rather customary to name three stages. The first develops the prodromal symptoms and proves the incapacity of the individual who has feelings of special well-being. The second begins with the seizure, emphasizes all the previous abnormalities and adds physical changes. The third has the pa- tient in bed. This disease has many variations: a convulsion may mark its introduction; the patient is sometimes in a condition to attract much atten- tion, but the course may go to its end without any happening of consequence. As to subgroups there are no clean-cut divisions. A demented type called typical goes from a gradual onset through a routine course. The expansive type attracts attention with extravagantly ridiculous de- lusions. The agitated form shows excitement, has extreme delusions, and runs a short course; while the depressed form often shows a clouded conscious- ness with delusions of self -accusation. The prognosis gives a three-year average, but the 64 MENTAL DISEASES expansive type may have periods of relative re- covery and live two, three or four times as long. In diagnosis it is well to have in mind the fact that an epilejDtiform convulsion for a man in mid- dle life, without a history of epilepsy, is suggestive. As already said, early recognition is often very important. Impaired judgment, a change of dispo- sition, moral obtuseness and self-satisfying, inade- quate explanations are grounds sufficient for sus- picion. Spinal fluid examination may be a valuable aid, when it can get as confirmatory evidence a positive Wassermann, Nonne's albumin test, Lange's gold chloride test, and a cell count of over 20. And these findings will at times be positive, while the Wasser- mann for the blood stays negative. The differentiation from an alcoholic psychosis is made when the alcohol is withheld. The other con- dition which may simulate the prodromal stage, is hysteria, but here the attitude of the paretic to- wards himself is essentially different for he never overstates personal discomforts, but later develops physical signs. In September 1914 a German mechanical engineer, thirty-two years old, was received here. Ten years before he had been treated for syphilis. During the year before commitment he came gradually from an energetic, cheerful disposition to be irritable. GENERAL rArwM.VSiS 65 He had a desire to have and spend money, l)ut no inclination to earn it. He became indolent, indif- ferent and imaginative. His wife wrote, "He spent foolishly all we had, yet thinks we are wealthy." At the time of examination he said, "I also invented that electric aeroplane, that big cast-iron one; you remember the time I went up in Seattle. It is made of three-inch armor i^late. I just invented it for commercial use. When I left, my wife asked for $15,000, but I gave her $500,000. I bought a lot of silk for seven dollars, but when I got home and opened the box there was $15,000 worth of silk." The Wassermann examinations for serum and spinal fluid were positive, Nonne jDositive and Lange's positive, the cell count 130 to the cubic millimeter. There have been some variations in the condition of this patient. Treated by the Byrnes method he had twenty-four intradural injections of mercury, as w^ell as intramuscular injections. On the whole the change has been one of increasing weakness and men- tal deterioration. In this period he has taken food with relish and been free from evidence of suffering. He died after being- bedfast for several months. CHAPTER VII PARANOIA Paranoia names a form of insanity which, though relatively infrequent, is known to the public through the newspapers because of different trials that have attracted general attention, with a defendant so mentally alert that in court it has been hard to show convincing reason for committing or holding him in restraint. In paranoia the life of an individual is marked with a system of delusions slowly developing from a series of false conceptions. The delusion is not the disease, but it is the one characteristic and es- sential feature of this psychosis. There is often some constitutional defect, with a family history in the background, while the recog- nized beginning in early adult life may be con- nected with some circumstance of strain or special disturbance. The general conduct ma}" be near normal, and the mental condition go without evidence of fault when conversation does not touch the diagnostic delu- sions. Pathologic studies are negative in their findings. CG PARANOIA G7 When the diagnosis is made it may be possible to go back through ten years and put together in- cidents that belong to an earlier picture. An in- sidious and gradual development is the rule. Ir- ritable conduct and an inclination to grumbling may be remembered, brightness or flightiness may have been remarked and also a tendency to suspicions that had a trivial cause or no cause at all. This last is an early characteristic and is of the most sig- nificance. The individual may show himself sensi- tive, distrustful and inclined to hold aloof even from friends. Ideas of persecution may take the victim away from his work from one place to another, gain- ing no more relief than a temporary respite, for the delusion is not long left behind. The man who is at first suspicious may lead him- self to the thought of definite persecution, from which he tries to go away but finds that he is per- sistently followed, and so in the end turns on his tormentors. This sentence is perhaps the statement of a history that runs through some years and ends with the development of a dangerous stage. When false interpretations finally give prominence to fixed delusions that show themselves shaping into a system, the paranoiac may be named as such. Other psychoses have delusions too, and in paranoid dementia precox these may be measurably fixed, but the paranoiac in all his earlier stages stays free from 68 IVrEl^TAL DISEASES Fig. 18. — Paranoia. This man states that he is a priest democrat and a social democrat. Claims that fighting is his business. Delusions fixed. PAIlANOrA G9 Fig. 19. — Paranoia. The discoverer of radium. Speaks easily, has abrupt self- confident manner, drops eyelids while talking. Has cynical expression. 70 MENTAL DISEASES Fig. 20. — Paranoia. PARANOIA 71 tlie other evidences of mental deterioration that go with dementia. His delusions have been well termed fixed, systematized and progressive, and are often neither absurd nor impossible. In fact, they are often so plausible that the unfamiliar mind can not be convinced of their falsity until other evidence appears. The developed paranoiac is rather the aristocrat of the asylum. Touching his system he is expected to stay impervious to reason. But at times this may be a buried fact and hard to get at. Often his as- sertions are found to be not carefully made, and this is so although at the same time he speaks with em- phasis and an extra show of confidence. Certain acts the patient may recognize as foolish, but for these he is ready to elaborate an explanation. At the end as in the beginning, the patient is found with a system of connected delusions influ- encing his life, but is not much marked by any other changes. The delusion of persecution, which is usually fun- damental, ma}'' lead into others as love, religion or grandeur, and there are cases of this sort that go on to develop a changed personality and to claim the identity of some distinguished name. Alienists quite generally agree that a genuine case of paranoia does not recover and is dangerous in his liability to commit violent assault. But recently / '1 ZMEXTAL DISEASES attention lias been called more to tlie interpretative attitude wliicli in this psycliosis seeks to study first the events in the patient's life that gave those ma- terial incidents from which the delusions were made, and then to know their manner of development and the extent of influence acknowledged in the life of the patient. The result has been to recognize dif- ferent paranoid forms as belonging elsewhere and also to slioAv reason for being somewhat less dog- matic in denying the possibility of effectiveness to every therapeutic measure. And the prognosis needs in each case to consider the individual, particularly in relation to the history of his delusions, their kind, degree of develoi^ment, and fixedness. This is im- 13ortant for, while recovery is not looked for, the immediate need of full supervision can thus be judged. As a class the paranoiacs are dangerous and clever, and persuasive. This cleverness may go with big schemes. Thus 'Mt. X. three years ago proved his ability to the em- barrassment of a well known comjDany in getting from them the acceptance of his note for over a million dollars for ninety days. And it was while selling stock under the plan thus arranged that he was taken into court and committed after a trial by jury. In the asylum he has since developed a system of fixed delusions in which those in authority, particularly the judge of the committing court, are PARANOIA I .) held associated with a conspiracy to restrain him illegally. In this connection he has made many de- tailed written statements, addressed to newspapers, attorneys and different prominent men. Comparative Table MANIC- DEPRESSIVE PSYCHOSES DEMENTIA PRECOX GENERAL PARALYSIS PARANOIA MENTAL DETERIORA- TION No marked change. Yes. Yes. No. DEr.USIONS Transitory and reasonable. Usual. Often of persecution. Frequently of ridiculous exaggerations. Systematized. HALLUCINA- TIONS Sometimes transitory. Frequent, especially hearing. Occasional. Rare. PSYCIIO-MOTOR ACTIVITY Retardation or hyper- activity. Indifference. Negativism. Occasional in- crease, but usually grad- ually progres- sive sluggish- ness. Usually normal. PRINCIPAL MENTAL SYMPTOMS Difficult thinking or flight of ideas. Isolation of patient. Out of contact with immedi- ate environ- ment. Fabrication of memory. Normal men- t al ' processes but fault in judgment. PHYSICAL SIGNS Incidental to disease stage. Circulatory disturbance. Katatonic type: muscu- lar tension and waxy flexibility. Pupillary and speech disturb- ance. Knee jerks vary; are often ex- aggerated. Negative. ORIENTATION Normal or apathetic, rarely delusional Normal. Becomes disturbed. Normal. CHAPTER VIII EPILEPTIC PSYCHOSES Epileptic feeble-mindedness with the classical grand mal or lighter petit mal is a subject belong- ing to general medicine, but in the study of legal and mental diseases acquires special importance for there is no other morbid state that so often holds responsibility for unprovoked criminal action. A social deterioration thus may shape a vagabond, or explosive violence lead to arson, murder or immoral offences. The variety of possibilities is hardly limited. The qu-estion of insanity msij be one for nice ad- justment, for the diagnosis must take well into ac- count the history of the case, the mental and phys- ical markings, and then judge as to whether the pro- tection of others or the welfare of the patient makes commitment advisable. With a story of violence that may be repeated, the need can not be set aside and crimes of exposure may settle the point, but there are other cases where the resources of the home are to be considered as well as the patient himself. EPILEPTIC PSYCHOSES - 75 Defective heredity is frequent. In this connec- tion parental alcoholism and epilepsy are to be spe- cially mentioned, though many other physical and mental faults are put in the same list. The pathology varies as does the cause, and so it is better to put the word in the plural and to speak of the epilepsies. The true epilepsy which has an obscure etiology usually is marked by sclerotic changes in the hippocampus major or a gliosis near the surface of the hemispheres. It is this form, with- out any clear etiology, that most often goes on to mental manifestations. The sjmiptom best known in epilepsy is the con- vulsion, but for convulsions there are different causes which at times can name a disease, and each of these as recognized in general medicine should have suffi- cient consideration. But it is a period of uncon- sciousness in connection with the convulsion that is of most diagnostic value. This may be very short or may last through several hours. And in close connection there can happen a preconvulsive or post- convulsive twilight stage, sometimes stretching through different days. And it is just at this time that the dangerous acts of an epileptic are likely to occur. Often there is evident confusion with fur- ther mental disturbance which may show various forms of indiscretion, and violence may immediately precede or follow the convulsion. But further it 76 MENTAL DISEASES must be held in mind that with rather obscure evi- dence for diagnosis there may be acts of a criminal nature for which the disease is the cause. Also, instead of any frank convulsion, there may be an epileptic equivalent, perhaps a recurring incident of confusion or depression, that in certain cases can prove a diagnosis of legal importance. The patient often shows marks of degeneration, as jug-handle ears or other malformations. There may be significant scars on the tongue or larger ones on the head. A clumsiness may go with the progres- sive feeble-mindedness. Some are quick-tempered or surly, with an easy change of mood, while others may be dull and good-natured with a hesitating, dragging speech that attempts a painstaking accu- rac}^ of detail. Hallucinations are rather the excep- tion, illusions may develop near the attack, and sometimes there are delusions of an extraordinary sort. In the interval the orientation is usually good and the conduct normal. A lumberman thirty-seven years old, admitted August 5, 1915, was five years in prison in Finland for shooting his father, and over ten jears ago was in this institution. As to the occasion of this recent commitment he says, "The}^ tell me that I got into a fight with another fellow. They took me to the hospital and then bring me here. I have had those spells since I was a boy. I don't know when they E1>1 LEPTrC! PSYOnOSKS 77 Fig 21-KpiIeptic insanity. Shows marks from fall, also some degree *=■ ' of dementia. 78 MENTAL DISEASES are coming because they come like lightning. It takes me in the brain and head and goes in. Some- times I would be sitting down. Most of the time it begins quick. I don't see anything when I have those spells. I had trouble with a woman, and when it come on that time it was like a cloud coming into my face and I was out (unconscious) about nine hours. ' ' Epilepsy is a disease of youth, and 75 per cent have been reported as beginning before the twentieth year. The jDrognosis is bad, but in some cases the in- tervals may be long. And in the degree of mental disturbance between patients there are big dif- ferences. CHAPTER IX ORGANIC DEMENTIA 1. Huntington's Chorea. 2. Multiple Sclerosis. 3. Cerebral Syphilis. 4. Tabetic Psychosis. 5. Arteriosclerotic Psychosis. 6. Brain Tumor. 7. Brain Abscess. 8. Cerebral Apoplexy. 9. Cerebral Trauma. The anatomic basis given in structural change is the common fact that brings these several psychoses into the same group. 1. Huntington's Chorea. — Huntington's chorea is a chronic and slowly progressive disease. Usually the beginning comes with the patient over thirty. There is no connection with Sydenham's chorea. The etiology is not kno^^ai, but the hereditary evi- dence is emphatic; generations may be skipped, but it is a disorder that belongs definitely to its own families. Pathologic changes as meningeal thickening, 79 80 MEXTAL DISEASES general brain atropliy and arteriosclerosis may cause the mental symptoms, while midbrain degenerations can explain the motor signs. The mental and physical symptoms may or may not come on together and grow evenly. The move- ments are irregular, incoordinated, slower than in acute chorea, often begin in the hands and are some- what under voluntary control. Facial muscles may be irregularly moved with the slow, loose jerks which show in a larger way in the muscle groups of the extremities and may involve most of the volun- tary muscles of the whole body. Gait is swaying. In the end walking and writing become impossible. The early mental changes have to do with a weak- ness of memory and judgment. There are grades of feeble-mindedness, often irresponsibility in work and irritability in conduct. These symptoms de- velojD and become comiDlicated with the physical con- ditions. The speech may be made explosive or in- distinct. Delusions and hallucinations are not fre- quent, and suicide seldom happens. The disease makes an uncontrolled progress. 2. Multiple Sclerosis. — Multiple sclerosis is a dis- ease with scattered sclerotic areas, pinhead size and larger, found irregularly in any part of the brain, cord, medulla, pons or cerebellum, and may involve the nuclei, roots or trunks of the cranial nerves; con- sequently there is a striking variety of s^Tnptoms. OR(!ANI(; I)EI\rKXTrA 81 The condition is relatively infrequent. In half the cases no cause is found. In others acute infections, chronic intoxications and heredity are named. Early adult life is usually the time of beginning. Motor disturbances are far more prominent than mental symptoms. JMuscular weakness is the rule and this comes often without atrophy. The gait shows stiffness and the feet drag on the floor. Mus- cle rigidity, intention tremor, nystagmus, scanning- speech, the easy fatigue of speech muscle, paresis of eye muscles, apoplectiform seizures, dull pains, neuralgia, dyspnea, optic neuritis, and ataxia are among the i^ossible symptoms, but any of these ma}^ be missing. Knee jerks and other tendon reflexes are increased, ankle clonus can be expected and Babinski's sign is frequent. Then mental disturbance is usuall}^ of a lesser de- gree and seldom is sufficient to take the patient to a hospital. Hallucinations Avith mild confusion, dif- ficulty in thinking and a faulty memory are evident, while periods of excitement or depression are pos- sible. Laughing and crying may be involuntary and indicate a muscular rather than an emotional fault. Apoplectiform and epileptiform attacks sometimes happen. The form of the symptom group depends upon the location and extent of the sclerotic patches. A gradual beginning of manifold symptoms, with im- 82 MEXTAL DISEASES provements and relapses, gives ground for suspicion while the tj^ical case goes on through a slow, un- even course to develop intention tremor, s^Dastic paresis, nystagmus, scanning speech, ataxia, in- creased reflexes, optic atrophy and apoplectic mani- festations, along with some limited involvement of the mentality and sensation, with also functional disturbances of the bladder and rectum. The prognosis has in mind a course marked by remissions, gradually progressive, running six months to ten years or longer. 3. Cerebral Syphilis (Vascular). — Syphilis may invade any part of the nervous system. The loca- tion and the degree of development control the clinical picture, which usually has a name of its own to indicate the structures that are diseased. AYithin the present decade laboratory studies have done much to establish sj^Dhilis as the direct and common cause of certain allied disease t^^Des, pre- viously distinguished by their clinical findings. Thus cerebral s^iohilis and jDaresis are nearer to- gether than they used to be. Whether the one may grow into the other is a question that has been an- swered both ways. The groups made by different authors somewhat vary. Jelliffe and White in 1915 take up cerebral syph- ilis as vascular and parenchymatous and regard this parenchymatous form as paresis. They call repeated OllGANIC DEMENTIA 83 attention to the fact that syphilis seklom limits it- self carefully to any one spot or tissue. Conse- quently, it is probable that the description of a pure tj^pe would often be blurred if the full path- ologic changes Avere known. In this fact lies one reason for the great variety of symptoms. In the vascular form a period, varying from a few months to fort}?- years, may come between the infection and the recognition of cerebral syphilis. Nearly half of these cases develop symptoms within three years. Headache, dizziness, insomnia and ap- athy are often prodromal incidents. In the begin- ning usually there is a defective memory and defec- tive judgment, with a failure to recognize these faults. There is likely to be an overconfidence in strength and abilitj^, and perhaps at the same time evident weakness of will. Periods of marked irri- tability usually come. Of clinical pictures there is an indefinite number. Some suggestive combination is expected. Among other findings the following may occur: Alterations of the pupil, choked disc, optic neuritis, vomiting, dementia cured by treatment, monoplegias, epilepsy, hemianesthesia, nerve disturbances, abnormal sleepi- ness, palsies, despondency, stupidit}^, character change, hallucinations, delusions, and characteristic writing. No one of these is essential, but often sev- eral are in association. 84 MENTAT. DISEASES The great value of the laboratory findings is now appreciated. Usually the Wassermann for the blood is 2^ositive. For the spinal fluid the Wassermann is likewise positive, also Nonne's albumin and Lange's gold chloride color tests; while the cell count, called normal at ten, is called abnormal at twent}'- and may go to one hundred or more. In cases where the symptoms are close to those of paresis, the findings may hold the diagnosis of cere- bral syphilis, but leave it a matter of opinion as to whether the syphilitic process has already gone from the vascular to the parenchymatous type. As stated above, sj^ahilis in the nervous system may involve any tissue within reach, be it brain or spinal cord or membranes, and the selection made is responsible for the clinical disease that follows. With the common cause recognized, the explanation of different overlapping pictures is helped. For tabes dorsalis and paresis the expression "para- S}T3hilis" has been used, but the occasion for this extra term is not beyond dispute, if these really are just forms of disease due to infection within the lim- its of cerebrospinal syphilis. The present classifica- tion is in the process of adjustment and can not be regarded as fixed. 4. Tabetic Psychosis. — Tabes dorsalis is a chronic poisoning caused b}^ syphilis. The examination of the blood and spinal fluid is now added to the other ORGANIC DEMENTIA 85 Fig. 22. — Organic Jciiiculia, laljctic ptjcliuM? 86 MENTAL DISEASES established clinical findings which belong to general medicine. In some cases there is mental disturbance. There may be forgetfulness, a showing of easy fatigue, as well as some changes in disposition. Sometimes there is a more abrupt beginning of the mental s^Tiip- toms, with the patient excited and restless, and then hallucinations of hearing are often prominent. Such a condition can clear and may recur. The orienta- tion is normal. In the tabetic psychosis the degree of deterioration is not progressive, and in this it is different from paresis. 5. Arteriosclerotic Psychosis. — Arteriosclerotic in- sanity is a chronic disease, but with jDaroxysmal clin- ical evidence, with s^miptoms that come and clear as allowed by the developments that have followed the changes in the cerebral arteries. Syphilis and alcohol are often mentioned as being responsible for the beginning. When there is a general systemic condition the factors usually prominent are chronic toxemia, hy- pertrophy of the left ventricle, high blood pressure, and a chronic nephritis. In such a case some atro- phy of the whole brain is expected, and thickening of the arterial walls. But the disease does not necessarily mean a gen- eral arteriosclerosis, for the condition may be re- gional and thus there may l^e even extensive cerebral ORGANIC DEMENTIA 87 involvement, without radial indication. A liigli blood pressure has been held suggestive, but it is not an essential point in the diagnosis, and some au- thorities have found it absent in over three-fourths of such cases. A limited portion of one hemisphere may show well developed arteriosclerosis, while a careful au- topsy fails to find evidence of arterial change in any other part of the body. Also this circumscribed le- sion may exhibit mental, motor or sensory symp- toms, in harmony with the special centers involved. The autopsy findings vary with the localizing in- cidents and the degree of the degeneration changes, which may be most marked about the vessels or close to the cortex. The ventricles may be dilated, local hemorrhages with extensive areas of softening- can occur, and an unevenness in the distribution of pathologic tissue is the rule. There is no pathognomonic symptom and between individual cases there is a good deal of difference. Often there is lessened energy and interest in work, together with forgetfulness and emotional depres- sion, perhaps also sleeplessness and irritability. Headache, dizziness and deafness are possible com- plaints. The dementia is progressive and shows in a growing inefficienc}^, in the loss of ability of emo- tional discrimination, in the failure of comprehen- sion, and in incoherence of speech. Hallucinations, 00 :\IEXTAL DISEASES delusions and a further confusion of thought come for some cases. Focal degeneration produces a dis- turbance according to the area involved. Thus speech, sight, hearing or some special faculty of the mind or hand may be lost. The end condition does at times leave the patient disabled and entirely de- pendent on the care of others. It is characteristic for these patients to hold well their own personality, which fact becomes a point of diagnostic consequence, for in senile dementia this is less true. The laboratory report helps to separate the general paretic. The diagnosis has to study the whole picture and then eliminate the other jDsychoses which come up for consideration. 6. Brain Tumor. — Brain tumors do not always have mental symptoms. Those that do, usually either touch the cortex or reach it by pressure. Tuberculosis and syphilis are the two prominent infectious causes, while in addition to true tumors there can occur developmental anomalies and aneu- rysms of the cerebral vessels. Both jDhysical and mental findings are controlled by the location and size of the tumor. The mental symptoms are not enough to give a diagnosis; that must have also all the signs available. And locali- zation calls for special skill in the study of the whole picture, for which reference is properly made OlUiANlC DEMEXTIA 89 to texts of a differciit soi't, Avliicli have direct re- ,i;-ard for the respoiisil^ility of the surgeon. Headache often comes early. Nausea, vomiting, dizziness, convulsions, paralysis, dyspnea, heart dis- turbance and optic nerve changes are suggestive symptoms which may occur in any combination, or all develop together. When a mental change conies it is of a sort that could belong to paresis or arteriosclerosis. Atten- tion and comprehension are at fault; the patient is slow in movement and thought, showing confusion, lack of interest and loss of energy; moral stand- ards are lost and delusions and hallucinations may be present. The size and site of the tumor limit the degree of disturbance, and the symptom group varies for each patient. Multiple sclerosis, tuberculous meningitis, and hysteria have also to be separated in the diagnosis, which the laboratory report and a full display of all signs and symptoms help to get through elimination. 7. Brain Abscess. — An abscess implies infection and in the brain it is most frequently a secondary development. There are not always mental symptoms. In some cases the clinical history is like cerebral tumor. Temperature and headache, with a slow pulse, may mark the beginning. Later an acute case can go to delirium or stupor. 90 MENTAL DISEASES 8. Cerebral Apoplexy. — Arteriosclerosis and sj^dIi- ilis are tlie diseases most frequently responsible for cerebral apoplexy. There may be a cardiovascular- renal involvement. A high blood pressure increases the liability, and a sudden change in the blood pres- sure may be the immediate cause. Under the term ''apoplexy" we include cerebral hemorrhage, throm- bosis and embolism, which are similar in the clinical manifestation by which the disaster is announced; though it should be borne in mind that while an em- bolism is abrupt, and a hemorrhage is usually so, a thrombosis is of variable duration in its develop- mental period. This is often followed by a state of confusion, random movements, and the doing of queer or unexpected things. The later condition is made by the residuals, which have to do with the preceding disease and the area invaded. A careful estimation of these remaining s^Tiiptoms sometimes can make localization possible and indicate the prognosis. 9. Cerebral Trauma. — A head injury can be of any degree, and thus the range of s^miptoms possible in cerebral trauma is indicated. Further, if there are complications, such as hemorrhage or any gross harm to brain substance, the j^icture shajDes accord- ingly. Unconsciousness may follow the injury, or a mental incapacity come on later. A befogged con- dition may clear slowly, and a loss of memory from ORGANIC DEMENTIA 91 Fig. 23. — Organic dementia, cerebral apoplexy. 92 IMEXTAL DISEASES the time of the accident is characteristic, while in some few cases the memory loss has antedated the accident, including a period of a week or more. The extent of cerebral cell injury rather measures the violence of the trauma, and even in many cases where no diagnosis of hemorrhage is made it is pos- sible that numerous minute scattered hemorrhages have occurred. A change in character is usual, along with phe- nomena of various sorts. The patient often shows weakness in ordinary movements and suffers from vertigo. He may be indifferent and passive or ir- ritable. Delusions sometimes come, or there may be a fabrication of memory and rambling speech. Disorientation, dejection, whining, incoherence, for- getfulness and tinnitus are other possible symptoms. An illustration of this type of a case is given in the history of a laborer committed to the Western State Hospital several months ago. The court pa- pers indicated that not much was known of the man. His mental disturbance had been increasing through a week. He was confused, rambling, disconnected and made exaggerated and contradictory statements. He was unable to find his way about; was put down as dangerous and brought to the asylum with the diagnosis of epilepsy. The records here show that on examination it was impossible to obtain any de- pendable history. After admission he had a number OlUIAXJCl DKMI'mTIA 93 Fig. 24. — Organic dementia, cerebral trauma. 94 MENTAL DISEASES Fig. 25. — Organic dementia, cerebral trauma. ORGANIC DEMENTIA 95 of severe epileptiform attacks. The befogged con- dition was slow in clearing ; later fabrication of mem- ory and disorientation as to time and place and per- sons were evident, and judgment delusional. Blood pressure was systolic 210 mm. The patient was for some time considered in a critical condition, and given neutral tub treatment in the hydrotherapy department. Through the month after admission the patient continued very much confused, but became able to state that his mind had been blank and that his last recollection while outside was of working in a log- ging camp, seeing a log coming towards him, and being hit on the head by the steel cable. This fact was confirmed by outside statement. Two weeks later the man was out working on the lawn, able to answer questions without confusion, eating well and sleeping well, and was without further seizures. Today the patient does not recollect his coming to this hospital nor the first of his stay here. His manner of speech is quiet and straightforward. There is no evidence of delusions. Blood pressure is systolic 170 mm. and diastolic 115 mm. The pro- visional diagnosis has been revised to organic de- mentia, cerebral trauma (Diefendorf), and it is ex- pected that he will soon be discharged. CHAPTER X INVOLUTION PSYCHOSES 1. Melancholia. 2. Presenile Delusional Insanity. 3. Senile Dementia. Various kinds of insanity may happen to come to a patient who has reached the period of physiologic involution, but melancholia, presenile delusional in- sanity and senile dementia are forms which have to do directly with the involution changes. 1. Melancholia. — By some it is claimed that mel- ancholia is a type of the manic depressive group modified by the changes of the involution period in which the ductless glands ma}^ figure, but this is not established beyond dispute. Melancholia is a psychosis characterized by anxi- ety, despair, and a grave persistent depression, to- gether with a suppressed agitation that shows phys- ically in muscular tension and increased psj^cho- motor activity. It is a chronic disease, usually slow in development and rather free from marked varia- tions in its course. The beginning comes often in the sixth decade; nearly two-thirds of the patients 96 INVOLUTION rSYOnOSES 97 Fig. 26. — Involution psychoses, melancholia. 98 MENTAL DISEASES are women, and about one-third go on to recovery. Neglect of work, indifference to the regular inter- ests of life and anxious worrying are early findings which may be accompanied by numerous physical discomforts and mental faults. Hallucinations are rather the rule, and may give the foundation for the delusions that follow. Self-condemnation often is a prominent sjanptom ; and a readiness to go with- out food can cause a loss in weight. The despond- ency is of a sort that does not lighten in response to incident or effort. The joossibility of suicide is the great danger that must be held in mind, because frequently this is a compelling thought, while the patient has the men- tality and physical ability that is sufficiently respon- sive to carry out such a threat. Arteriosclerosis, some nerve cell degeneration, and limited atrophy of the brain are the most frequent autopsy findings. Mrs. H., who came to this hospital in 1913, was then quiet, orderly and depressed. She was near fifty, had grieved greatly over the death of her hus- band, and talked of killing herself. When nerv- ous she saw and heard all kinds of things. Sexual excitement was marked. She had somatic delusions and said she had blood poisoning and cancer. Then there were restless spells and a strong craving for xvoi.uTioN l's^■(;ll()SKs 09 Fig. 27. — Involution psychosis, melancholia. 100 MEXTAL DISEASES sedatives. Slie at times "would bite herself, and at night sometimes saw skeletons dancing about the room. Also she seemed conscious of the presence of her dead husband, and had delusions that grew out of hallucinations. There was a period of im- provement, but later she failed again. There was loss in weight and increase in depression; she grew noisy and had unclean habits. She complained of a devil in her throat urging her to kill. 2. Presenile Delusional Insanity. — Presenile delu- sional insanity is an infrequent diagnosis. It usu- ally begins in the fourth decade with symptoms that suggest a dementia precox modified by the change of adult life. The prominent symptoms are irrita- bility, with a progressive dementia that allows a great variety of unstable delusions. These delu- sions may have to do with bodily derangements, suspicion, persecution or infidelity. Charges of un- speakable conduct will not, however, hold the pa- tient from his usual association with the persons involved. The orientation stays- normal. The con- duct shows a general irresponsibility. 3. Senile Dementia. — For patients around sixty years of age, one of the most frequent conditions leading to conunitment is senile dementia. The organic changes upon which this jDsychosis depends are of a progressive sort. General atrophy of the INVOLUTION PSYCHOSES 101 Fig. 28. — Involution psychosis, presenile delusional insanity. 102 MENTAL DISEASES brain is definite and characteristic. There is an in- crease of the cavity fluid, cell degeneration, arterio- sclerosis, and sometimes minute scattered hemor- rhages. Some authors do not formall}^ recognize this psy- chosis; others go into subdivisions. At any rate the patients for sucli a group are here in the hos- pital; they are too difficult to be taken care of at home. Some hereditary tendency and a high blood ipves- sure are often in the background, while sickness, mental strain, or other hardship may be the precipi- tating incident. Recovery is not expected. There is gradually in- creasing evidence of the disease. Most such cases are in the hospital less than five years. The mem- ory is bad for recent events, but dwells more in the early past. The patient comes to live in the past and this fault in memor}^ may in some considerable degree be a factor in the conduct, which shows er- rors in judgment, careless improprieties and per- haps a tendency to be negligent, to destroy or to pilfer. The thought processes are slow and show confusion. The mood shifts and may be irritable or despondent. Distrust and suspicion will some- times color the delusions that may grow out of il- lusions or hallucinations. A broken, restless night INVOLUTION PSYCHOSES 103 Fig. 29. — Involution psychosis, senile dementia. 104 MENTAL DISEASES in which the' different symptoms are worse is the rule, as is also a daytime drowsiness. Among the jDhysical signs, high pulse pressure, tremors, joartial paralysis, tinnitus, diminished sen- sibilit}^, and small, uneven pupils often occur. CHAPTEE XI CONSTITUTIONAL INFERIORITY AND DEFEC- TIVE MENTAL DEVELOPMENT 1. Constitutional Inferiority. — Constitutional in- feriority is a name that may be used in classification for a group allowed arbitrarily to include certain borderline psychopathic states. Most of the cases thus considered are weak individuals with a defec- tive heredity, who have often suffered further in an unfortunate environment. The evident fault may go in one direction or another and get some further name according to the psychopathic feature that is made prominent. Nervousness, dejection, excite- ment, compulsion neurosis, and sexual perversions are manifestations that mark different types. Of course, many such individuals are in their own homes, but when the difficulty of their care and con- trol passes a certain point it becomes necessary to provide institutional supervision. 2. Defective Mental Development. — Defective mental development differs from dementia in that the individual never has had ordinary mentality. 105 106 MEJ^ITAL DISEASES Fig. 30. — Constitutional inferiority. Note jug handle ears. DEFECTIVE MENTAL DEVELOPMENT 107 There are different grades; the most severe is called idiocy and hardl}^ goes beyond mere existence, an adult going no further in development than a child iM«. :a.—c< iliiiiiul inferiority. of three. A better ability, but one that does not go beyond the age of seven, can belong to an imbecile, while the term "moron" or high grade imbecile is 108 MEXTAL DISEASES Fig. 32. — Defective mental development, imbecility. DEFECTIVE MENTAL DEVELOPMENT 109 used hy some when the ability corresponds with that of a cliihl Ix'tweeii seven and twelve years of age. Fig. 33. — Defective mental development. See doll in hand. The imbecile is usually recognized in childhood. He shows variations from normal conduct, may be morbidly stupid or overactive and irritable; often IIU MEXTAL DISEASES shows a lack of sense of responsibility and an incli- nation towards many improprieties. Fig. 34. — Defective mental development. Usually an imbecile will make some improvement under instruction, but does not develop enoug'li to take care of himself. CHAPTER XII INTOXICATION PSYCHOSES 1. Acute Alcoholic Intoxication. 2. Chronic Alcoholism. 3. Delirium Tremens. 4. Korsakow's Psychosis. 5. Acute Alcoholic Hallucinosis. 6. Alcoholic Hallucinatory Dementia. 7. Alcoholic Paranoia. 8. Alcoholic Paresis. 9. Alcoholic Pseucloparesis. 10. Morphinism. 11. Cocainism. 1. Acute Alcoholic Intoxication. — For certain in- dividuals, the effect of alcohol taken freel}^ regularly goes beyond what may be termed physiologic drunk- enness, and in these cases acute alcoholic intoxica- tion is properly put as a psychosis. The pathologic evidence comes with the extreme exhibition of particular symptoms, as anger which may lead to violence, or despondency with attempts at suicide, or destructive acts, or a shamelessness that has no reserve, and instances of this type can 111 112 MEl^TAL DISEASES be expected to repeat this picture whenever the cir- cumstances are favorable. 2. Chronic Alcoholism. — Tolerance for alcohol va- ries greatly, but where used persistently it marks more or less every organ in the body. There are demonstrable changes in the brain and cord. In- flammation of the membranes, some general atrophy, dilatation of the ventricles, and localized arterio- sclerosis are among the findings. The heredity is often bad, and drinking habits on the part of the father are common enough to be sig- nificant. The mental deterioration is slowly progressive. It becomes hard to give attention to the matter in hand. Inditference, forgetfulness, negligence, and irritability may be associated with faults in judg- ment and an open disregard for customary i^ropri- eties. Illusions, hallucinations and delusions of jeal- ousy are all possibilities. Also there are physical signs. Perhaps the most characteristic is the fine tremor that shows best in the hand, and thus in the writing. There are various disturbances in the sen- sibility of the skin. Partial paresis, and lesions of the optic nerve and retina can happen, and occasion- all}^ there are convulsions. This dementia is like others in being gradually progressive, but differs in having its alcoholic his- tory which is essential to the diagnosis. INTOXICATION PSYCHOSES 113 Chronic alcoholism provides the foundation upon which several of the intoxication forms can develop, 3, Delirium Tremens. — Delirium tremens comes to those who are chronic users of liquor, often at the time of a debauch, but alcohol alone is not a suffi- cient cause. Usually the history gives additional circumstances that overstrained, weakened, or shocked the individual and produced functional dis- turbance. The beginning may be abrupt, but prodromal rest- lessness, loss of appetite, irritability, and insomnia are the rule, and there may also be a definite dislike for liquor expressed. The mental disturbance that follows is marked by vivid hallucinations of which there is a great vari- ety; cannons and bells, angels or devils, monkeys and snakes are more or less common. The illusions may show as a tendency to see spots and believe them crawling. The delusions are shifting. They may be fanciful and grotesque and commonly dis- play fear. The patient frequently shows anxiety and excitement, but occasionally is inclined to be jovial. And along with all of this there is a definite confusion which leads into delirium. Sometimes there are lucid intervals. The part of the memory best held is for the remote past. Physically there is the tremor of small muscles that shows specially in the hand, face and tongue. ll-i MENTAL DISEASES Fever, albuminuria, double siglit and parasthesias are other findings. The prognosis is good for nine out of ten. Some go quickly to the fatal end. 4. Korsakow's Psychosis. — In Korsakow's psycho- sis there is a lack of impressibility, a loss of memory for recent events, together with a fabrication that is characteristic. The case is nearly always one of chronic alcoholism with the signs of a poljaieuritis. There ma}^ have been recurrent delirium tremens, but other intoxications sometimes give the apparent cause, and further instances are reported as occur- ring in paresis and senile dementia. The pathologic changes mark both brain and cord, and are of a sort that might belong with a severe alcoholic toxemia. Minute cerebral hemorrhages can explain the variety of focal symptoms. The lack of impressibility is perhaiDS responsible for the loss of memory for recent events, and also for the confused orientation. It is characteristic that lapses in thought bring out fabrications. These are often far away from the facts, but are plausibly put, and even when outlandish or impossible seem to fully satisfy the patient. This tendency to fab- rication can usually be further drawn out by ques- tions. In other connections the judgment may be apparently normal. iNTOxr(;ATi()X psy(Utof;ks 115 The mood of different patients or of the same pa- tient at different times may indicate anxiety, indif- ference, apathy, irritability, or good hnmor. Some make a gradual improvement, onongh so that they can again take np th(Mr work, l)nt more develop a dementia that goes away from recovery. 5. Acute Alcoholic Hallucinosis. — Hallucinations of hearing, leading to delusions of persecution, nearly always mark the beginning of an acute alco- holic hallucinosis. Conversations are overheard in which all manner of evil statements are made con- cerning the patient and his affairs. These delusions may quickly develop some loose paranoid jDattern. The commencement is usually abrupt and the an- tecedent history alcoholic. Often there is insomnia, anorexia, loss in weight, and a tremor of hands and tongue, but on the whole the ]3hysical signs are not marked and the patient is rather free from restless- ness. The relation to delirium tremens is close, and there are borderline cases, but in acute alcoholic psychosis there is relative freedom from disorientation, cloud- ing of consciousness, and physical disturbances. Further, the prominent and characteristic hallucina- tions are those of hearing. The prognosis looks to a recovery made after sev- eral weeks, but some cases become chronic. IIG MEXTAL DISEASES 6. Alcoholic Hallucinatory Dementia. — When de- lirium tremens or acute alcoholic hallucinosis par- tially clears only to later lapse into a chronic state marked with hallucinations and giving general evi- dence of dementia, the diagnosis may be revised to alcoholic hallucinatory dementia, and certain other cases may be put here without a reclassification. The patient hears voices that threaten him, in imag- ination he suffers at the hands of his persecutors physical harm as well as indignities of various sorts. The delusions tend to become of paranoid type, are more or less persistent and are kept up without much change. Frequently they concern the body and may show some sexual phase. Anxiety or irri- tability may mark the conduct at first, but later there is generally some humor in the attitude. Without alcohol, progress may be stopped, but real recovery is not expected. 7. Alcoholic Paranoia. — Delusions of a paranoid type occur with several different psychoses. When a chronic alcoholic condition is responsible, the de- scriptive term "alcoholic paranoia" can be used. In such a case delusions of jealousy are often con- nected with circumstances that permit the possibil- ity of the charges made, but the reasons given are not of a sort to carry conviction and may be entirely absurd. Thus, some trivial incident may be men- tioned as proof of infidelity. It is characteristic INTOXICATION PSYCHOSES 117 that the most grave statements made do not dis- turb the readiness of the patient to associate in or- Fig. 35. — Intoxication psychosis, alcholic hallucinatory dementia. dinary manner with those whom he accuses. Hal- lucinations of hearing are at times present. Es- trangements within the family can be understood. 118 MEI^TAL DISEASES AVitli alcohol taken away, temporary improvement is expected, but not recovery. 8. Alcoholic Paresis. — ^AYhile a diagnosis of alco- holic paresis has sometimes been used, it is probably better that such a case should be known as paresis, with certain extra findings for which alcohol is re- sponsible, as delusions and hallucinations of infi- delity, the alcoholic tremor, and neurotic s^inptoms. However, it must be borne in mind that according to circumstances the alcoholic picture or the paresis may develo^D first. 9. Alcoholic Pseudoparesis. — Certain instances of marked alcoholism may simulate i)aresis. Chronic alcoholism with a sudden beginning of mental disturbance, carelessness of manner, feelings of well-being, delusions of grandeur, pupillary varia- tions, a muscular fault that shows in speech, writing and gait, together Avith tremors and painful joints, makes proper the name "alcoholic pseudoparesis." A differential diagnosis notes the history, the gen- eral prompt imiDrovement when liquor is stopped, and the laboratory examinations of blood and spinal fluid. ATitli alcohol stopped, the patient goes on to recovery or develops some degree of a chronic alco- holic dementia. 10. Morphinism. — In this country morphinism nearly always has begun in the taking of the drug to relieve pain. The susceptibility of different in- INTOXICATION PSYCHOSES 119 dividuals varies mucli. Often the habit is estab- lished before it attracts attention. A weakness that is muscular, mental and moral conies gradually. Temporary stimulation is obtained from each in- jection, but is followed by a period of reaction to which belong all the disturbances due to toxemia and the craving that can only be allayed by a grad- ually increasing dose, which may go to forty grains or more. If there be such a thing as a truth center in the brain it is certainly injured by the use of this drug. At first for gratification, but soon to vainly diminish the distressing urge, it is taken. Some ob- servers, however, believe that heroine still more readily leads. to moral insanity. Irritability is usual, also faults of judgment, lack of purpose, and mental enf eeblement ; some cases show illusions and delusions. Morphine locks up the secretions, contracts the pupils, and gives an itchy, dry skin which, when a localized symptom, takes the hand frequently to the nose. There are many incidental discomforts, with a tendency to complain of the same. Often the skin gives plain evidence of repeated hypodermic punc- ture. Examination has found albumin and glycosuria. Ataxia, cachexia and collapse are possibilities. With the full removal of the drug there can be recover}^, but the liability to recurrence is great. 120 MENTAL DISEASES 11. Cocainism. — Cocainism is rather usually com- plicated by the taking of some other drug as mor- phine. The symptoms are for the most part those of morphine, but the developments towards disturb- ance come quickly. Hallucinations are likely to be vivid, and frequently the sensation of objects felt beneath the skin is distinctive. Delusions of a dis- turbing sort may have to do with persecution or in- fidelity. The patient is overenergetic but fails to accomplish much. The degree of excitement leads to uncontrolled and bizarre conduct. Cocaine di- lates the pupils. Abstinence from the drug promptly brings mitigation of its effect, but the permanency of recoverv is alwavs doubtful. CHAPTER XIII THYROIGENOUS PSYCHOSES 1. Myxedema. 2. Cretinism. Both myxedema and cretinism are understood to be conditions that develop because of a failure in the internal secretion of the thyroid gland, which as a hormone ma}^ control processes of growth in other tissues. 1. Myxedema. — Myxedema following surgical re- moval of the thyroid gland has made an opportunity to study the group of symptoms. Now operative myxedema is rare, but the full relation of the gland to the idiopathic type is established. Adolescence or later is the usual time of beginning. Often the rough, thickened skin comes first along with the atrophy of the gland. Hands are thick and clumsy; genital anomalies are frequent; the bones thicken and fail in development. Lumpy, large, fatty masses may show in the supraclavicular spaces or on the arms. Metabolism is slowed and leads to faults in digestion. Faults in nourishment show sometimes with the nails brittle, the hair dry, and the teeth 121 122 MENTAL DISEASES loosened. The movements seem slow and difficult. The mental action also drags and suggests a lack of interest. The degree of mental and physical changes varies from a mere stiffness in manner and thought to restlessness with insomnia, anxiety, and delusions, that indicate the mental possibilities of this psychosis. The blood has eosinophiles. White and Jelliffe give a congenital form that near the time of weaning develops rapidly, but usually does not live to grow up. 2. Cretinism. — The word "cretinism" is allowed as the name for a condition marked by the display of certain mental and |)hysical changes, beginning in the very young and being slowly progressive. The cause is thjT^oid defect in function; and one theory is that this is the effect of some water-borne noxious element, got from the ground in certain districts. This so-called '^endemic cretinism" has the bones shortened, with various anomalies and deformities. The skin is thick, loose and wrinkled. The neck is short and thick, the face swollen, the tongue thick, and the whole figure clumsj'. The sex organs fail in normal growth. Nutritive processes are sluggish. The child is apathetic and dully inactive. Arrested development is apparent. Frequently there is sen- sory impairment, especially of hearing. The men- tal evidence is a mass of faults, but there is much difference between individuals; some never reach THYROKIENOUS PSYCIIO.SKS 123 Fig. 36. — Taken at age of 5 years. Thyrogenous psychosis, cretinism. 124 MENTAL DISEASES coherent speech, while others are even near normal. There may be goiter with decreased secretion, or atrophy of the thyroid, and frequently the hypo- physis is enlarged. Early injury to the gland can cause sporadic cretinism. Also aberrant types oc- casionally occur. CHAPTER XIV INFECTION AND EXHAUSTION PSYCHOSES (a) Infection Psychoses. 1. Fever Delirium. 2. Infection Delirium. 3. Postinfection Psychosis. (b) Exhaustion Psychoses. 1. Collapse Delirium. 2. Acute Confusional Insanity. 3. Acquired Neurasthenia. When an infection is at all serious it develops some degree of exhaustion; also where exhaustion lowers the resistance the liability to infection is in- creased. Thus infection psychosis and exhaustion psychosis often overlap and have their symptoms entangled. However, this occurrence may not hap- pen, so the conditions are separately described, with recognition of several clinical groups. Infection Psychoses 1. Fever Delirium is a mental disturbance that ac- companies fever, and the degree of resistance to 125 12n MEXTAL DISEASES its development indicates tlie measure of mental stability. The duration has somewhat to do with the picture because this is inclined to bring symp- toms rather in a routine order. Four grades are observed. The beginning has sensitiveness to light and noise, headache, restlessness and insomnia; the second has confusion and hallucinations; in the third, motor symptoms are increased and lack con- trol; while in the fourth consciousness is dulled, the movements have no i^urpose, the muttering is in- coherent, and coma with death then expected. 2. Infection Delirium names the mental state that may come in an early stage of infection, the cause of which brings the typical signs of its own disease. Distention of the blood vessels in the cortex may be responsible for confusion of thought, disorientation, excitement, flight of ideas, hallucinations and delu- sions. 3. Postinfection Psychosis indicates an exhaus- tion, or the continued effect of a toxemia not fully cleared away. The patient fails to get back his for- mer interest and energy. The mood is sad. There may be shifting hallucinations. With a further de- velopment there often are delusions of persecution, disturbing voices, and grinning faces. The one who suffers thus may be quarrelsome or tempted to sui- cide. INFKCTroN AXI) FA'TTAI'STTON PSYCTTOSES 127 Exhaustion Psychoses 1. Collapse Delirium is infrequent. Loss of blood and shock are tlie principal causes, and infection can indirectly have an influence. Everything seems changed and gives reason for perplexity. Restless- ness, insomnia, and confusion are common. Violent psychomotor activity, full disorientation, incoher- ence, illusions, hallucinations, and delusions are all possible. 2. Acute Confusional Insanity has causes such as loss of blood, illness, and mental strain. Perplexity is apparent. There is clouding of consciousness with motor excitement and incoherence. The whole pic- ture is not as abrupt or acute as in the case of col- lapse. Anxiety, restlessness, forgetfulness, prostra- tion, various physical discomforts, also mental faults due to confusion, emotional unevenness, and lucid intervals are all among the findings occasionally recorded. The course of such psychosis usually lies within a three months period. 3. Acquired Neurasthenia is a term that may be used for chronic nervous exhaustion. It is a condi- tion that belongs usually to the period most exposed to extra mental strain, which is between twenty- five and forty-five. An early training that lacks discipline, and allows a deficiency in character de- velopment, increases the liability. Heredity can pro- 128 MENTAL DISEASES vide a predisposition, and an irregular life tends to lessen normal resistance. The provoking cause can be overwork, but often it has also to do with the continued effort made to meet the various demands that overcrowd daily life. In this connection it is to be kept in mind that there is a great difference between individuals as to what constitutes over- work. In some measure the condition is the direct out- come of the fatigue of a nervous system that has not been allowed sufficient relaxation, but it is more to be regarded as a chronic intoxication to which various irregularities, both nervous and physical, have contributed. Because of the circumstances, the beginning can not belong to any exact date. The individual per- haps, grows irritable, and is inclined to a tiredness that is all out of proportion to what has been done. Thinking becomes an effort, attention is difficult and easy distractibility evident. It costs an effort to stay at regular work. Amusement does not rouse the interest. There is a variety of physical faults, especially functional disturbances. Head pains are frequent, and deficiencies in elimination far reach- ing in their consequences. Discomforts of all sorts are exaggerated so constantly that this is a point in differential diagnosis. Patients show anxiety as to their health. Usually they appreciate their own INFECTIOiSr AND EXHAUSTION PSYCHOSES 129 inefficiency, and worry over the fact. Emotional in- stability shows with impulsiveness. Usual results in work are not reached. There may be noted ab- normalities in sensation. Broken nights tend to in- crease the apparent nervousness. Muscle twitching and a tremor in the eyelids and hands are possible incidents. Disturbances in digestion can be expected to bring a certain train of symptoms. Such patients are inclined to demand much of others, without seeming to realize the unreasonableness thus shown. The findings all put together shape a new picture for each separate case, and diagnosis must then eliminate the different forms of dementia. If the cause can be recognized and sufficiently mitigated, then the prognosis may become favorable. CHAPTEE XV PSYCHOGENIC NEUEOSIS 1. Hysterical Insanity. 2. Traumatic Neurosis. 3. Dread Neurosis. 1. Hysterical Insanity is the name used to desig- nate a certain mental state that becomes responsible for a kaleidoscopic display of physical symptoms which suggest particularly a lack in normal control. It is possible that the best explanation has to do with a dissociation within the personality of the indi- vidual. The origin of the word carries the ancient Greek belief that the cause lay in the womb, while the pres- ent teaching considers the influence of repression in the sexual sphere. The subnormal, poorly endowed, and unevenly balanced constitution is most exposed to this psy- chosis. The symptoms are of a sort calculated to attract attention and gain sympathy. There is often an evi- dent emotional excitement that can lead to impul- sive acts. Actual occurrences, incidental hardships 130 PSYCHOGENIC NEUROSIS 131 or illnesses, are liable to gross exaggeration, with emphasis being given to unimportant detail. Such patients complain about trifles and do not get away from a self-consciousness that gives an ill-founded importance to all that concerns them. The physical symptoms also are manifold and in- clude various erratic sensory disturbances. The list of possible symptoms is indefinite, but all the way through it is characteristic that the relation of cause and effect demanded by physiology and anatomy is disregarded. The degree of development varies with the pa- tient, but some reach a befogged state marked by silly excitement or epileptiform convulsions. This psychosis belongs to youth or adult life. The course is not progressive. The prognosis as to any period of special development is good, but the chance of recurrence is accepted. 2. Traumatic Neurosis. — One author gives trau- matic hysteria as a synonym for traumatic neurosis and develops the subject accordingly; another al- lows traumatic neurosis to have traumatic neuras- thenia and traumatic hysteria as subdivisions, and believes the definition should be broad enough to include the result of psychic as well as physical shock; a third puts traumatic neuroses and psycho- ses together in the title of a chapter ; while a fourth quite rearranges the grouping. However, if the 132 MENTAL DISEASES origin of the word is to protect its meaning, a neu- rosis should limit itself to a functional disturbance of some certain part of the nervous system, without any mechanical lesion sufficient to be a full cause. Taken thus, traumatic neurosis is hardly a mental disease, but it may become an important factor in adding mental to physical symptoms and thus be enmeshed in its own consequences. A logger was struck by the roll of a falling tree, and suffered a fractured rib and a bruise of the left shoulder. He had hospital care, until dismissed as in condition for work, and feeling well himself. When he started to work the movement of the arm brought pain, so he stopped, came to town, and stayed with his brother. Some three weeks later, when examined, the story given was of a condition not progressively worse. Upward movement of the arm brought pain, but with gentle force the hand could be put on top of the head. With the arms moved up, there was a muscle twitching at the back of the left shoulder. For the left side of the trunk and left arm there was diminished sensibility to ex- ternal stimuli, much of the time a hemicrania, the extended hands showed a tremor, and for both eyes the field of vision was somewhat limited. In the case of this patient it is believed that the accident did certain actual injury, but not of a sort to be re- sponsible for all of the several sjTnptoms recorded. PSYCHOGENIC NEUROSIS 133 Sometimes the Mannkopf test is of help. Pressure on a point alleged to be painful is made with the pulse under observation; when there is actual pain usually the reflex action quickens the rate. The course may stretch into months or years, but with the aggravating conditions removed, the prog- nosis is good. 3. Dread Neurosis is developed out of a psychic trauma and, displaying some certain anxiety, comes to limit and color everything for that individual. Commonly some of the more frequent and ordinary acts are involved. The beginning may be connected with an illness or some temporary fault that sug- gests thoughts of fear, which through subnormal judgment may enter at the point of least resistance and become established. The dread may concern itself with any ordinary physical act, or with the inability to do other things that belong to the life of the patient, and this fear having invaded some particular field is progressive there. Some instances go on to full incapacity and show extreme suffering, but it is characteristic that pain of some actual physical sort is philosophically accepted as belong- ing to its cause. The course is tedious, but recovery may come. CHAPTER XVI COXSTITUTIOXAL PSYCHOPATHIC STATES: UNDIAGNOSED PSYCHOSES: INCIDENTAL COMMENTS Tlie constitutional psychoijcitliic states gives an ap- propriate name under which can be classified cer- tain individuals of pathologic mentality, who can not well be diagnosed within any one of the ordinary fonns of mental disease, but who have a defect in character that has developed far enough in some one direction to get a name for itself; thus, there is criminalism, emotional instability, inadequate per- sonality, nomadism, paranoid personality, path- ological liar, sexual psychopathy, also other forms. A hospital classification properly makes a place for those ''not insane" and not classified. The com- mitment examination occasionally is done under circumstances of disadvantage, as in the case of a foreigner who speaks only his own language and does not have an interpreter; or where some condi- tion of confusion or other disturbance really belongs to general medicine. In such instances it may be advisable that the patient have hospital care pend- ing the development of the diagnosis. 134 COXSTITUTIOXAL PSYCHOPATHIC STATES 135 In other cases there may be evidence beyond dis- pute of mental fault, and yet in the group of symp- toms, too much of a dei3arture from any recognized t}T3e to be well placed with a label. This confusion can come when one mental disease has been compli- cated by a second, or when the patient is too atypical in signs and sjmiptoms to be put within the defini- tion of any one psychosis. For, while in the scheme of a classification the dividing lines are w^ell drawn, in practice these may be rubbed out by borderline patients. In the naming of a mental disease, the procedure is sometimes easy, without dispute, and likely to stay without change. But again, as noted in the chapter on Examination, there are cases where con- tinued observation gets additional facts, special ex- aminations add technical information, and the pass- ing of time allows comment as to the progressiveness of the condition, and thus may prove the wisdom of a provisional diagnosis open to revision. Of the different mental diseases there are two which stand ajDart as being nearer to the normal than the others. Epilepsy and the manic depressive group have in common what is often a fully ra- tional interval. Just then on immediate evidence such a loatient could be judged sane, but it is more reasonable to speak of recovery from the attack and 136 MENTAL DISEASES to have in mind the liability of its return. The fre- quency and character of the attacks give data for an opinion as to the manner in which such a patient would probably conduct himself away from hospi- tal supervision. CHAPTER XVII SHELL SHOCK Shell shock has not been formally classed as psychosis, but inasmuch as one fifth of the pres- ent war disabilities are thus listed, the subject claims serious attention. The sjTuptoms and signs vary. They are both physical and mental. Often the latter are the more prominent. Usually the sufferer is befogged, disoriented, and shows amnesia. He does not hear orders, may laugh or cry, and is liable toi wander away with- out any effort at keeping out of danger. Involun- tary movements, twitching, spasms, jerks, or even convulsions can happen. Cases of temporary blind- ness or deafness accompanied by frightful halluci- nations are recorded. Profuse sweating is a com- mon symptom, and the shock patient often starts from sleep in terror. Some shoAv xDeculiarities of gait awkwardly dragging heavy feet, carry their bodies twisted towards some trench position, or per- haps develop monoplegia. The type and variety of manifestations has the range of traumatic hysteria. It was observed that 137 138 MEXTAL DISEASES many cases happened Avithout exposure to any ex^ ternal violence, and this led to the belief that a large part of the whole group were iDroperly in- stances of a psychoneurosis ; a functional distur- bance without any definite pathological background. Doctor M. Allen Starr in a brief article* skill- fully reviews the most recent studies that have to do with the evidence of physiological and patholog- ical changes found in shell shock. The soldier is taken rather abruptly from his home, carried through a tim^e of intensive training, put in the battle area where first he sees the wound- ed and hears stories of atrocities, and then is him- self in the front trenches waiting. The alertness and tension demanded produce as secretions the body substances needed to supply the muscles nour- ishment for strenuous activity. A¥hen opportunity of relief in action is denied, these same substances reabsorbed become toxic. Babbits kept aAvake one hundred hours die, and the brain cells show depletion. The same findings are made when a rat is frightened to death. This is the change of exliaustion, and it is believed that men may suffer from similar cause. Further, autopsies in shell shock cases have found multiple scattered minute hemorrhages (sometimes hundreds) which explain disconnected s^^njotoms. *See Scribner's Magazine, August, 191S. SHELL SHOCK 139 Atmospheric loressure in the vicinity of a large shell becomes ten tons to the square yard, then yields to a corresponding depression. Such an ahrui^t change in atmospheric pressure can produce bubbles of gas in the blood which do damage as em- boli. These are given as some of the explanations for shell shock. It is probable that a strict psychoneurological ex- amination made by the draft boards could have done much to protect the army in its record, for connnonly the essential ground work lies in the in- dividual himself, and the weakest always breaks first. However, in many instances the causes re- ferred to give full organic evidence for the develop- ment of all the findings gotten in shell shock. INDEX Alcoholic i>sychosis, 111 Apoplexy, 90 Argyll Eobertson reaction, 59 Arteriosclerotic psychosis, 86 Ataxia, 23 G General paralysis, 57 H Hallucination, 23 Huntington's chorea, 79 Hysterical insanity, 130 Babinski's sign, 81 Brain abscess, 89 Brain tumor, 88 Cerebral syphilis, 82 Cerebral trauma, 90 Cocainism, 120 Constitutional inferiority, 105 Constitutional psychopathic states, 134 Cretinism, 122 Criminalism, 134 D Delusion, 23 Dementia precox, 40 Dread neurosis, 133 E Emotional instability, 134 Epileptic psychoses, 74 Examination, 25 Exhaustion psychoses, 127 Illusion, 24 Imbecile, 107 Inadequate personality, 134 Infection psychoses, 125 Insanity, 22 Involution melancholia, 96 Involution psychoses, 96 K Katatonia, 47 Korsakow 's psychosis, 114 M Manie depressive psychoses, 30 Melancholia, 96 Mental deficiency, 105 Morphinism, 118 Moron, 107 Multiple sclerosis, 80 Myxedema, 121 N" Nomadism, 134 141 142 IlfDEX Orientation, 24 Paranoia, 66 Paranoid personality, 134 Pathologic liar, 134 Presenile delusional insanity, 100 Pressure of activity, 24 Psyeliogenic neurosis, 130 Psychomotor activity, 24 Psvchosis, 24 S Senile dementia, 100 Senile psychoses, 96 SheU shock, 137 Spinal fluid examination, 64 Tabetic j)sychosis, 84 Thyrdigeuous psychoses, 121 Traumatic neurosis. 131 Traumatic psychoses, 90 COLUMBIA UNIVERSITY This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. 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