;v<.ro. ■ ■ « ^^m ■ ^H Columbia SJntoeisitp mtijeCttptfJImltork College of logicians ano burgeon* Htbrarp MANUAL OF PSYCHIATEY. BY J. ROGUES DE FURSAC, M.D., Formerly Chief of Clinic at the Medical Faculty of Paris. AUTHORIZED TRANSLATION FROM THE FRENCH BY A. J. ROSANOFF, M.D., Junior Assistant Physician, L. I. State Hospital, Kings Park, N. Y. EDITED BY JOSEPH COLLINS, M.D., Professor of Diseases of the Mind and Nervous System in the New York Post-Craduate Medical School ; Physician to the New York City Hospital; Neurologist to the Montefiore Home for Chronic Invalids ; Consulting Neurologist to the Hospital for Ruptured and Crippled, the Long Island State Hospital, and to the Manhattan State Hospital, West. FIRST EDITION. FIRST THOUSAND. NEW YORK : JOHN WILEY & SONS. London: CHAPMAN & HALL, Limited. 1905. R£>3 Copyright, 1905, BY A. J. RGSANOFF. ROBERT DRUMMOND, PRINTER, NEW YORK. e TRANSLATOR'S PREFACE. The new classification of mental diseases introduced by Kraepelin has met with much opposition from the medical profession in general, although a great many alienists have adopted it. Since this classification is based upon no firmer foundation than the empirical one of clinical observation, it cannot be doubted that from a strictly pathological standpoint some of the groups are quite heterogeneous, and that ultimately further subdivisions, changes in the grouping, and additions will be necessary. But to the practical alienist the advantage of Kraepelin's classification over the older ones is very considerable. By a careful examination of the history and of the physical and mental status the alienist is now able in the majority of instances to assign his case to one or the other of the great groups and thus to determine the prognosis with a greater degree of certainty and accuracy than was possible formerly. This constitutes the chief advance of the Kraepelin school; and it is the result not of the changes in the nomenclature, but of an essential depart- ure in the methods of taking the mental status and in the interpretation of the manifestations of the diseased mind. Diagnostic difficulties, of course, arise as they do in iii iv TRANSLATOR'S PREFACE. all clinical work; but a really serious drawback lies in the fact that a considerable proportion of any series of consecutive cases is found to be unsuitable for inclusion in any of the groups; whether these cases are formes jrustes of the different morbid entities or whether they are really conditions which are not covered by this classification cannot at present be determined. A word to the beginner in psychiatry. The nomen- clature and methods of the insanity clinic differ so greatly from those of general medicine that the average student will find the chapter on special psychiatry almost unintelligible without a careful preliminary study of those on general psychiatry. This is the case with this more than with most other similar works, since for the sake of brevity no detailed descriptions of the individual psychoses are given in the second part; there is in most cases a mere mention of the symptoms, for the recognition and interpretation of which the student is referred to the first part. The translator has tried to follow closely the text of the French original. Several slight changes have, however, been found necessary. The French insanity law has been omitted. The spec- imens of insane utterances showing incoherence and flight of ideas have been obtained from the clinical records of cases at the Long Island State Hospital at Kings Park, N. Y., as it was found impossible to make a satisfactory translation of the French specimens. The translator's notes throughout the book are en- closed in brackets. A. J. ROSANOFF. Kings Park, N. Y., January 1905. TABLE OF CONTENTS. PAGE Translator's Preface iii Introduction ix FIRST PART: GENERAL PSYCHIATRY. CHAPTER I. — Etiology 1 Multiplicity of causes in psychiatry. — General and individual predisposing causes. — Pathogenesis of degen- eration. — Congenital predisposition. — Morbid heredity. — Acquired predisposition. — Physical and moral deter- mining causes. II. — Symptomatology. — Disorders of Perception 29 Insufficiency of perception. — Illusions. — Hallucina- tions: properties common to all hallucinations; the different varieties of hallucinations; theories of hal- lucinations. III. — Symptomatology (continued). — Consciousness. — Memory. — Associations of Ideas. — Judg- ment 55 Unconsciousness. — Clouding of consciousness. — Disorientation. — States of obscuration. — Hypercon- sciousness. — Different forms of amnesia. — Distortions of past impressions. — Enfeeblement of the attention. — Flight of ideas. — Incoherence. — Imperative ideas. — Fixed ideas. — Autochthonous ideas, — Disorders of judgment. — Delusions. v vi TABLE OF CONTENTS. IV. — Symptomatology (continued) . — Affectivity. — Re- actions. — Personality 79 Morbid indifference. — Exaltation of the affectivity. — Morbid depression, joy, and anger. — Aboulia. — Auto- matic reactions. — Suggestibility. — Impulsiveness. — Stereotypy. — Negativism. — Disorders of ccenesthesia. — Alterations of personality. V. — The Practice of Psychiatry. — Examination of Patients. — General Therapeutics of the Psychoses • 99 Anamnesis. — Direct examination. — Simulation and dissimulation. — Insane-asjdums. — Commitment, phy- sician's certificate. — Medico-legal questions: respon- sibility. — Treatment of excitement, of suicidal ideas, and of refusal of food. SECOND PART: SPECIAL PSYCHIATRY. Classification 121 I. — Deliria of Infectious Origin: Febrile Delirium. — Infectious Delirium Proper. — Hydrophobia. ... 124 II. — Psychoses of Exhaustion: Primary Mental Con- fusion; Acute Delirium 129 III. — Acute Alcoholic Intoxication (Pathological Drunkenness) 138 IV. — Chronic Alcoholism: Permanent Symptoms. — Eti- ology. — Epidosic Accidents: Delirium Tremens; Alcoholic Systematized Delirium 142 V. — Chronic Intoxication by the Alkaloids: Mor- phinomania. — Cocainomania 163 VI. — Psychoses of Autointoxication, Acute and Sub- acute: Unemic Delirium. — The Polyneuritic Psychosis 173 VII. — Thyrogenic Psychoses: Myxcedema. — Cretinism... 180 VIII. — Dementia Precox. — Chronic Delirium 180 TABLE OF CONTENTS. vil CHAPTER PAGE IX. — General Paresis 211 X. — Mental Disorders Due to Organic Cerebral Affections 250 XI. — Psychoses of Involution: Affective Melancholia. — Senile Dementia 256 XII. — Manic Depressive Insanity: Manic Type. — De- pressed Type. — Mixed Types. — Attacks of Double Form. — Periodic Insanity. — Alternating Insanity. — Circular Insanity 268 XIII. — Reasoning Insanity (Kraepelin's Paranoia) 292 XIV. — Constitutional Psychopaths: Mental Instability. — Sexual Perversion and Inversion. — Obsessions. 298 XV. — The Mental Disorders of Epilepsy 311 XVI. — The Mental Disorders of Hysteria 321 XVII. — Arrests of Mental Development: Idiocy and Imbecility. — Moral Insanity 327 INTEODUCTION. Psychiatry is that branch of neurology which treats of mental disorders and of the organic changes asso- ciated with them. Mental disorders arrange themselves in two funda- mental categories, characterized respectively by insuffi- ciency and 'perversion of the intellectual or moral facul- ties. Insufficiency may be either congenital or acquired. In the first case it constitutes an arrest of development; in the second, psychic paralysis. When the psychic paralysis is temporary, causing a suspension, but not a destruction, of mental activity, the name psychic inhibi- tion is applied to it; on the other hand, when it is per- manently established, it constitutes intellectual enfeeble- ment or dementia. Perversion of the intellectual and moral faculties may also be congenital or acquired. Generally it results from an exaggeration of the mental automatism, and is designated by different terms, depending upon the particular function affected: hallucinations, delusions, morbid impulses, etc. is x INTRODUCTION. Mental diseases or psychoses are affections in which the mental symptoms constitute a prominent feature. They differ from such mental infirmities as idiocy, moral insanity, and many states of dementia, in that they are expressions of active pathological processes and not of permanent and fixed alterations of the mind. Psychic infirmity, when not congenital, occurs as the ultimate outcome of some mental disease. The rela- tion between the two conditions is analogous to that which exists between ankylosis of a joint and the ar- thritis which produced it; the latter is a disease, the former an infirmity. When mental symptoms appear to exist alone, the mental disease is said to be idiopathic, and is called a vesania; when they are associated with alterations of the organic functions the disease is said to be symp- tomatic or secondary. This distinction is superfluous, and the subdivision resulting from it is artificial. In fact, the more the efforts of alienists are directed to the study of the coexisting somatic disturbances, the more restricted does the number of the vesanias become. The psychopathic processes which Kraepelin has designated by the term dementia prgecox have for a long time been classified under various headings among the vesanias. Now, the number of physical signs observed in this affection (disorders of the tendon and pupillary reflexes, of the internal secretions, and of the general nutrition) is increasing from day to day; dementia prsccox is therefore looked upon not as a purely mental affection, but as an affection of the entire organism with con- comitant manifestations which are chiefly, but not INTRODUCTION. xi exclusively, mental. Such is also the case with primary mental confusion and with the melancholias, and the time is not remote when, with great benefit to psy- chiatry, the conception of the vesanias will be rele- gated to history. Two terms still remain for us to define: mental alienation and insanity. Although they are often employed indiscriminately, their meaning is not abso- lutely identical. Etymologically, an alienated (Lat. alienus) indi- vidual is one who has become " estranged" from him- self, who has lost the control of his intellectual activity, who, in other words, is not responsible for his actions. Unfortunately this definition rests upon the meta- physical conception of the free will and cannot find a place in medical science, which must be based upon observation and must adhere to demonstrable facts. It is better to adopt an essentially practical definition, as has been done by most modern alienists, and to designate by the term mental alienation the entire class of pathological states in which the mental disorders, whatever their nature be otherwise, present, an anti- social character. Not every individual suffering from a psychic affection is necessarily alienated. This term can be applied only to those who, on account of some mental disease or infirmity, are likely to enter into conflict with society and to find themselves, in con- sequence, unable to be an integral part of it. The term insanity has a more restricted meaning than mental alienation. Generally it is applied to states of mental alienation which result from a psy- chosis, i.e., in which the mental disorder is an expres- xn INTRODUCTION. sion of an active pathological process. An idiot or a clement is alienated but, except in cases presenting complications, not an insane person. This manual is divided into two parts. The first part treats of general psychiatry and comprises a study of the causes, symptoms, and treatment of mental disorders, considered independently of the affections in which they are encountered. The second part is devoted to special psychiatry, that is to say to the study of the individual psychoses. It has been thought advisable to devote a considerable space to general psychiatry, at least as far as the limits of this work would allow. A precise if not an extensive knowledge of the most important elementary psychic disturbances would seem to be altogether indispensable for a full understanding of the genesis and evolution of the psychoses. MANUAL OF PSYCHIATRY. PART I. GENERAL PSYCHIATRY. CHAPTER I. ETIOLOGY. "On studying closely the etiology of mental diseases one soon recognizes the fact that in the great majority of cases the disease is produced — not by a particular or specific cause, but by a series of unfavorable con- ditions which first prepare the soil and then, by their simultaneous action, determine the outbreak of in- sanity." 1 An individual of neuropathic ancestry and himself tuberculous, alcoholic, and exhausted, has an attack of melancholia. Shall we attribute the attack to the exhaustion, alcoholism, tuberculosis, or heredity f It is probable that all these enter into the causation of the Griesinger. Die Pathologie und Therapie der Geisteskrankheiten. 2 MANUAL OF PSYCHIATRY. attack, but it is difficult to determine the part played by each of them and to isolate the specific pathogenic agent. While it is justifiable to distinguish theoreti- cally predisposing causes and determining causes in psychiatry, it is very difficult to decide whether any given cause belongs to the one or to the other group. The same pathogenic agent, for instance alcohol, may in one case create a predisposition which is brought into play by some subsequent causative factor; in another case it merely brings out pre-existing predispo- sition. The subdivision of the causes of mental diseases into two groups, one comprising the predisposing causes and the other the determining causes, is there- fore merely schematic. But as it has many advan- tages from a didactic standpoint, it is adopted in this work, the reader being again reminded that such sub- division is more or less arbitrary. § 1. Predisposing Causes. " Mental diseases require for their development a soil in an especially modified condition of long stand- ing." 1 The mind does not succumb to the pathogenic action of the causes which we shall study later on as determining causes, unless its power of resistance is below the normal. A predisposition, latent or apparent, congenital or acquired, is necessary for a mental disease to originate and develop. Properly speaking, psychoses of the cerebrum validum do not exist. The predisposing 1 Joffroy. De V aptitude convulsive. Gazette hebdomadaire de medecine et de chirurgie, 11 fevrier 1900. ETIOLOGY. 3 causes therefore play an essential part in the etiology of mental diseases. They are classified into general and individual. General predisposing causes. — The action of the general predisposing causes is exerted upon commu- nities, and not upon isolated individuals. They are: race, climate, social position, occupation, age, sex, and civil condition. The influence of race 1 in the causation of psychoses is little known on account of the absence of sufficient statistical data. The Hebrew race is said to furnish a large proportion of neuropaths and psychopaths. It seems that among some races certain psychoses are particularly rare; thus general paresis is of very excep- tional occurrence among Arabs and African negroes. The study of climate likewise gives us but little definite information. While it is indisputable that cer- tain affections, such as cretinism, appear most frequently in certain countries (Valais), it is on the other hand altogether conjectural that the inhabitants of moun- tainous regions are more liable to insanity than those of the plains, as has been stated by some authors. 2 A priori it seems likely that the climate of warm countries exerts a debilitating influence upon the ner- vous system and thus favors the development of mental VBuschan. Einfluss der Basse auf die Haufigkeit von Geisteskrank- heiten. Read at the Convention of German alienists at Dresden, 1894. — Meilhon. La folie chez les Arabes. Annales medico- psychologiques, 1896, T. Ill et IV. — Goltzinger. Les maladies mentales en Abyssinie. Revue russe de psychiatrie, 1897, No. 33. — Duncan Greenlers. Mental diseases among the natives of Southern Africa. The Journal of Mental Science, 1895. 2 Lombroso. Uhomme de genie. 4 MANUAL OF PSYCHIATRY. disorders, especially in Europeans. I have found no statistics proving this; but an argument in favor of this supposition appears to me to be in the fact that a much larger number of suicides occurs in French and English troops while stationed in tropical countries than while living in Europe. While in France itself the number of suicides in the army is 29 per 100,000 soldiers, in Africa it rises to 69 for the same number of men. In the English army the proportion is 23 to 100,000 in the British Isles, and 48 in India. 1 The influence of the seasons has been more carefully studied. According to Gamier, 2 who has taken for the basis of his work the number of admissions to the special infirmary of the poorhouse from 1872 to 1888, the frequency of mental alienation attains its maxi- mum in June, and its minimum in January. During spring the number of admissions rises, to fall again during the latter part of summer and during autumn. The heat is evidently not the only factor, since the greatest number of cases does not correspond with the highest temperature of the year. 3 It is interesting to note the almost complete parallel- ism existing between the annual curve of mental aliena- tion and that of suicide. The statistics of Jeck, 4 based 1 Archives de medecine et de pharmacie militaire, Nov. 1892. 2 Gamier. La folie a Paris, 1890, p. 18. 3 "I intentionally omit the discussion on the action of the atmos- pheric conditions, which is but little known. Stormy weather favors the occurrence of agitation in the insane. ... As to the influence of the lunar phases, it is, to say the least, entirely hypothetical." V. Toulouse. Causes de la folie, p. 147. * Selbstmord und Jahreszeit. Frankfort Gazette, Sept. 24, 1898. Reviewed in Centralblatt jilr Nervenheilk. u. Psychiat., Dec. 20, 1898, ETIOLOGY. 5 upon about 100,000 cases of suicide, show us that the highest point of the curve is in June and the lowest point in February, exactly as it is in the case of mental alienation. Social factors play an important role in the etiology of mental diseases, as may be seen from a study of the history of the negro race in America. Before their emancipation the negroes were forced to hard labor, but were beyond the intense struggle for existence, had no cares, and were governed by rigorous rules of morality ; in those times they were almost totally exempt from mental disorders. " Insanity was almost unknown among them." l Since their emancipation, having been given not only the rights but also the burdens of free men, they have abandoned themselves without restraint to all excesses, and mental alienation has become implanted in their race, so that in this respect they have now nothing to envy their former masters. Civilization, by the stress that it imposes upon indi- viduals, by the physical and moral want that is hidden beneath its brilliant exterior, and by the constantly increasing migration of the inhabitants of the country toward the large cities, which it brings about, con- tributes to the production of predisposition to insanity. It is therefore not surprising that the number of in- sane is constantly increasing in the so-called civilized countries. However, this increase is not as considerable as it appears at first giance; for its accurate estimation it is necessary to keep in mind two factors that are 1 Witmer. Geisteskrankheiten bei der farbigen Rasse in den vereinigten Staaten. Allgemeine Zeitschrift fur Psychiatrie, 1891. 6 MANUAL OF PSYCHIATRY. often neglected, viz., the increase of the population, and the housing of patients, many of whom in former times lived at large and did not enter into the statistics. It is well, therefore, while recognizing the serious character of this increase, not to exaggerate its extent. According to Esquirol's statistics the number of unmarried insane exceeds that of the married ones. Tolouse states that many individuals remain single because they are already abnormal, and in many cases they subsequently become insane. Celibacy itself cannot therefore be incriminated; marriage, on the contrary, brings into play certain factors favoring the development of mental disorders, — in men by the in- creased strain imposed upon them, and in women by the various accidents which motherhood entails. 1 Illegitimate children seem to be more liable to in- sanity than legitimate ones. This is partly due, un- doubtedly, to the anomalous situation in which society places these unfortunates; but in many cases there is also a hereditary influence. It is probable that the parents of illegitimate children are often abnormal (Joffroy ) . All ages do not equally predispose to insanity. Though rare in childhood, by reason of the rudimentary state of the psychic functions, mental disorders are, however, not unknown in that period of life. 2 Insanity attains its maximum of frequency between the ages of thirty- 1 The influence of the puerperal state is to be considered later on with some detail. 2 Manheimer. Le troubles mentaux de Venfance, 1900. — Rodiet, JJalcoolisme chez V enfant. ETIOLOGY. 7 six and forty years among men, — when the struggle for existence is most intense, — and between the ages of twenty-five and thirty-five years among women, — when the burdens of maternity are greatest. Two other periods of physiological development pre- sent an increased predisposition to insanity; one cor- responds with the age of puberty (from fourteen to twenty-four years), 1 the other with the onset of senility (seventy years, according to Ziehen). 2 Finally, in women an increased predisposition is noticed at the period of the menopause. In a word, all those periods of life which involve a strain of the organism expose the individual to men- tal disorders, whether such strain be due to the physio- logical development of the organism or whether it be imposed upon it by the exigencies of life. The occupations involving the use of certain poisons (lead, phosphorus) may under unhygienic conditions favor the appearance of insanity. 3 Railroad employees furnish a large proportion of general paretics. Per- haps, as Huppert says, the constant jarring of the nerves due to the vibration of the cars is to be held responsible for this; or it may be due to the heavy responsibility which rests upon the employees of even the lowest grades, as is suggested by Sprengeler; or possibly it is to be attributed to the alcoholic excesses so frequent among this class of people. 4 1 Ziehen. Les psychoses de la puberte. Congres internat. de m6decine, Paris, 1900. — Marro. Les psychoses de la puberte. Ibid. 2 Ziehen. Psychiatrie, p. 210. 3 Quenzeil. Ueber Bleipsy chosen. NeurologischesCentralblatt,1899. 4 Hoppe. Beitrag zur Kenntniss der progressiven Paralyse. Allgemeine Zeitschrift fur Psychiatrie, Vol. 58, No. 6. 8 MANUAL OF PSYCHIATRY. Physical and moral want, isolation, and absence of steady occupation are among the predisposing factors, and often constitute potent causes of relapse in re- covered patients discharged from asylums. The number of insane is almost the same in the two sexes. While certain etiological factors, such as stress and alcoholism, predominate in the male sex, the puerperal state and lactation in the female sex re- establish the equilibrium. Possibly the number of insane women even slightly surpasses that of insane men. Individual predisposing causes. — The predisposition to contract mental disease is but one of the manifesta- tions of a more general pathological condition which has been designated by the term degeneration. Degener- ation affects the entire organism and constitutes under its different forms — psychopathies, neuropathies, ar- thritic manifestations, etc. — the feature of a large pathological class in which the insane constitute but a simple group. The predisposition may be congenital or acquired. Though, as is more frequently the case, degenerates are such from the day of their birth, still one may become one of that class later on in life, as a result of infectious diseases, of intoxications, or possibly of a defective mental and physical education. 11 Congenital predisposition exists in more than half or in about two-thirds of the insane." 1 A morbid heredity constitutes its most frequent cause, but not the only one. Many authors confound hereditary with 1 Morselli. Manuale delle malattie mentali, p. 38. ETIOLOGY. 9 congenital predisposition; wrongly, however, for "One may be a congenital degenerate, yet not one by heredity." x By heredity is understood the existence in the ascendants of a normal or pathological pecu- liarity which is transmitted to the descendant. But, for instance, a mother suffering from Bright's disease, and without psychopathic taint, may give birth to a degenerate son, predisposed to mental alienation. This would not be a case of hereditary predisposition in the true sense of the word, and still it is one of congenital degeneration. Heredity is direct when it passes from the parent to the offspring; atavistic when it skips a generation; col- lateral when the direct ascendants have been spared but the defect is found in one or several collateral relatives. It is similar when the anomaly present in the descendant is the same as that in the ascendant; in the opposite case it is dissimilar. The latter form is by far the most frequent, for, as Hunter says, " There are, properly speaking, no hereditary diseases, but only a hereditary predisposition to contract them." All possible evi- dences of degeneration are observed among the ascend- ants and the collateral relatives of the insane : neuroses, psychoses, organic nervous diseases, defects of character and morals [criminality], arthritic manifestations, gout, diabetes, etc. Heredity is convergent when the father and the mother both belong to families of degenerates. The relative frequency of this form reveals the curious fact that there is a peculiar mutual affinity among psychopaths (Fere). 1 Fere. JLa Famille nevropathique, p. 38. Paris, F. Alcan. 10 MANUAL OF PSYCHIATRY. A priori this accumulated degeneration would seem to give rise to particularly grave consequences. At times it produces genius. It is to convergent heredity that the bad influence of consanguinity is to be attributed. Consanguineous mar- riages do not create the defects, as is the general belief among the laity ; they merely accentuate the tendencies of the family, whether these tendencies be good or bad, and therefore cannot exercise a bad influence except in degenerate families. 1 Degeneration has, according to Morel, a tendency to become more pronounced from generation to generation. The final product of this retrogressive evolution is the idiot, who, sexually sterile, or placed in social positions which prevent his leaving a posterity, constitutes the last offspring of the degenerate race. This progressive march is quite frequently encountered. 2 The law of Morel 3 is, however, not absolute ; degeneration may be effectively combated in the individual by appropriate physical and moral hygienic measures, also by favorable intermarriages. If all families presenting hereditary de- fects were doomed to decay and death, the human species would long ago have become extinct. Degeneration, without being hereditary, may result from a pathogenic influence acting upon one of the parents at the moment of conception, or upon the mother during pregnancy. Thus endogenous or exo- genous, acute or chronic intoxications, infectious diseases, 1 Peiper. Consanguinitai in der Ehe und deren Folge fiir die DexcewJenz. Allg. Zeitschr. f. Psych., Vol. 58, No. 5. 2 Doutrebente. Ann. nu'd. psych., 1869, II, p. 385. - Morel. Traite da> maladies ?nentales, p. 575. ETIOLOGY. 11 stress and violent emotions, by their action upon the parents, often become causes of degeneration. Chronic alcoholism is encountered with particular frequency in the parents of psychopaths and neuropaths; it produces all possible forms of degeneration, but creates more par- ticularly a special morbid disposition which Joffroy has termed the convulsive tendency. Many children of alco- holic parents die of convulsions at an early age, and of those who survive more than 50% become epileptics. 1 Infectious diseases and traumatisms sustained by the mother during pregnancy often exert a harmful influence upon the psychic development of the offspring; and the same is the case with physiological privations, painful emotions, etc. The " children of the siege" — those of the Parisian population who were born just after the siege of Paris and the Commune — furnished a very large proportion of individuals predisposed to insanity. In the cases of twin pregnancy, 2 the influence of the factors of degeneration manifests itself frequently in an identical manner in the two children, who present at the same age the same mental disorders. 3 It is probable that twin pregnancy is in itself a cause of degeneration, the nutrition of two foetuses being effected under less favorable conditions than that of a single fcetus. 1 See statistics of Martin quoted by Joffroy. De V aptitude con- vulsive. Gazette hebdomadaire de medecine et de chirurgie, 11 fevrier, 1900. 2 Serge Soukhanoff. Sur la jolie gemellaire. Ann. med. psych., sept.-oct. 1900. 1 The same similarity may be observed in children of the same family independently of twin births. (Trend. Maladies mentales familiales. Ann. mod. psych., Janvier, 1900. — Fouqu6. Maladies mentales familiales. These de Paris, 1899.) 12 MANUAL OF PSYCHIATRY. All the causes here enumerated, including heredity, act upon the germ, the embryo, or the foetus, producing an anomaly of development. The pathogenic influence is exerted not only upon the nervous system, the resist- ance of which is reduced and the development impeded, but upon the entire organism, bringing about the mal- formations which we shall study later on, — the physical signs of degeneration. Each of the causes which we have enumerated can produce all the forms of degeneration, and it is conse- quently impossible to determine the character of the degenerative disorder from a study of the pathogenic agency which caused it. This proves the fact that the pathogenic agent, " whatever be its nature, always acts in the same manner, " namely, "by diminishing the em- bryogenic energy." " There is therefore nothing sur- prising in the fact that degenerates by heredity do not differ from those by parental nutritive disorders, since degeneration results generally from disorders of embryo- genesis, which are ultimately reduced to disorders of nutrition." 1 Acquired predisposition results from the influence of the same causes which bring about congenital predis- position. 2 But its action is exercised directly upon the individual, instead of indirectly, through the medium of his progenitors. The younger the subject the more deep- rooted and durable is the predisposition which he ac- quires. The infectious diseases and the nutritive dis- orders of infancy frequently give rise to cerebral and 1 Fere. Luc. tit, p. 231. 2 Toulouse. Les causes de la folie, p. 30. ETIOLOGY 13 meningeal complications which result in convulsions and impede the development of the nervous system, thus causing either an actual defect or a predisposition which may not become manifest until much later in life, in some cases not before senility. Finally, predisposition may be acquired during youth or adult age. The later their action the more difficult it becomes to distinguish the predisposing from the deter- mining causes. Here we may recall the hypothetical case of alcoholism, mentioned at the beginning of this chapter; alcoholism may act in some cases as a predis- posing cause and in others as a determining cause, and it is not always possible to establish with certainty its mode of action. § 2. Determining Causes. As we have shown above, according to most alienists all the insane belong to the class of individuals present- ing a neurotic predisposition ; it does not, by any means, follow from this, however, that all those who are pre- disposed become insane. Save in the instances in which there is a congenital psychic infirmity, such as idiocy, moral insanity, or epilepsy, most of the psychoses are acquired and supervene in individuals previously sound in mind or at least free from evident and grave mental disorders. Thus we are forced to assume that some new factor must cause the cropping out of a pre- viously latent morbid tendency. The study of the determining causes is therefore of great practical interest. We can do nothing against a predisposition except in an indirect and general way, 14 MANUAL OF PSYCHIATRY. by means of physical and moral hygienic measures, the effects of which may be felt only by the coming generations. The determining causes are, on the con- trary, directly accessible; in many cases we can either remove them or combat them. An example will render this idea clearer: Three individuals are from their birth equally charged with a hereditary predisposition. One of them leads a quiet and regular life, free from overwork and excesses. In him the predisposition remains latent, and his life passes without the occur- rence of mental disturbances. The second becomes addicted to alcoholism and in course of time develops the usual signs of the intoxication; but, conscious of his danger, he abandons his intemperate habits and recovers his health. Lastly, the third gives himself up to the same excesses as the second, but, instead of stopping in his fatal descent in time, he remains an inveterate drunkard and, becoming demented, ends his days in an insane asylum. These three individuals have had very different fates, because the first has escaped the determining cause, the second was prudent enough to combat it, while the third has entirely abandoned himself to its influence. The determining causes may be subdivided into physical and moral. Physical determining causes. — We are to congratu- late ourselves upon the present activity among alien- ists and neurologists in the investigation of the etiological relations of toxaemias, auto-intoxications, and infections. We shall see in the course of this work that many new, interesting, and important data have already been obtained through these researches. ETIOLOGY. 15 The germs of infectious diseases elaborate toxins the action of which does not differ essentially from that of chemical poisons, such as alcohol or cocaine. The infectious diseases and the intoxications therefore form in psychiatry two groups that are very closely related etiologically and even clinically. We distinguish mental disorders which are coincident in time with the infection itself from those that follow it. Only the former present specific features and merit the name of infectious psychoses. They appear some- times in the prodromal period, but more frequently they supervene at the height of the disease, and become alleviated or aggravated coincidently with the other symptoms of the infection. The psychoses which follow infectious diseases depend upon the general exhaustion which accompanies con- valescence. They appear chiefly as acute confusional insanity or as chronic psychoses terminating in dementia (dementia prsecox). In the latter case the mental disease usually does not break out until several weeks or even several months have passed after the infectious disease. I have seen in Joffroy's clinic a case of catatonia which appeared three months after a very severe attack of scarlet fever. Possibly the primary affection brings about a general disorder of nutrition which does not become manifest until the lapse of a period of greater or lesser duration. The confusional insanity and the chronic psychoses which follow infectious diseases do not present any special features and do not deserve to be classed as independent morbid entities. In their symptomatology and evolution they are identical with the same con- 16 MANUAL OF PSYCHIATRY. ciitions when caused by traumatisms, overwork, auto- intoxications, and other agents. All the acute infectious diseases may give rise to mental disorders : the eruptive fevers, septicaemia, erysip- elas, typhoid fever, gonorrhoea, etc. 1 The post-infectious psychoses are of very frequent occurrence after in- fluenza. Well recognized since the epidemics of recent years, they present no specific features, as was pointed out by the authors who were the first ta make a study of them (Pick, Schmitz). 2 The mental disorders often seen in the course of acute articular rheumatism are always the consequence of meningeal complications which either accompany or alternate with the articular inflammations. 3 The mental disturbances due to malarial infection may be classified in three groups. In the first group are those which are associated with the attack of malaria; these rightly belong to the febrile deliria. In the second are those which take the place of a febrile at- tack, constituting a form of malaria larvata. In the third are those which occur as complications of the cachexia of the pernicious forms. These disturbances present no pathognomonic features, and only a knowledge of a history of the 1 Joffroy. Fievre typhoide et folie. Congres de M6decine mentale, 1891. — Colombani. Troubles psychiques dans les affections genito- urinaries de Vhomme. These de Paris, 1900. 2 Schmitz. Ueber Geistesstorungen nach Influenza. Allg. Zeitschr. f. Psychiatrie, 1891. 3 Griesinger. Pathologie und Therapie der Geisteskrankheiten. — V. Mabille et Lallemand. Les folies diathesiques, 1891. ETIOLOGY. 17 disease and the recurrence of the attacks furnish the possibility of making a diagnosis. 1 The mental disorders of hydrophobia will be described separately. Among the chronic infections two are deserving of special consideration, namely, syphilis and tuberculosis. Syphilis, as we shall see later on, is a factor of primary importance in the etiology of general paresis. It may also cause mental disorders by the localized lesions which it gives rise to (arteritis, gummata, areas of meningeal inflammation). The frequency of tuberculosis, especially that of the lungs, in insane asylums, has long been known. Es- quirol has mentioned its frequency in melancholiacs. According to Hagen, 2 mortality from tuberculosis is five times as frequent among the insane as it is among the mentally sound; in France, according to Brouar- del, only three times. More recent statistics seem to show that these alarming proportions are somewhat exaggerated. According to Heimann, pulmonary tuber- culosis is not notably more frequent in the popula- tion of asylums than it is in the normal population. It cannot be denied, however, that certain psychoses, through the nutritive disorders which are associated with them, favor its development. But in mental alienation 1 Lemoine et Chaumier. Des troubles psychiques dans Vimpalu- disme. Ann. med\ psych., 1887. — Krafft-Ebing. Zur Intermittenz Larvata. Arbeiten aus dem Gesammtgebiet der Psych, und Neuropath., No. I, 1897. — Daniel Pasmanik. Ueber Malaria- Psy chosen. Wiener medic. Wochenschrift, 1897, Nos. 12 and 13. 2 Quoted by Heimann. Die Todesursachen bei Geisteskrankheiten. Allg. Zeitschr. f. Psychiatrie, Vol. LVII, No. 4. 18 MANUAL OF PSYCHIATRY. tuberculosis is not merely an effect; it may also be a cause. Chartier x has made an interesting study of the mental disorders connected with tuberculosis. He distin- guishes four classes of cases: (a) The pyschosis originates during the course of consumption ; (b) It alternates with the tuberculous exacerbations, and constitutes a sort of tuberculous equivalent; (c) It appears after the apparent cure of the pul- monary affection; (d) It develops in a subject tainted with latent tuberculosis, i.e., tuberculosis which does not present the usual symptoms of pulmonary invasion by the bacillus of Koch. In England a special clinical form has been described under the name of tubercular insanity, which develops in three stages. The first stage is marked by change of character — " unsociability, irritability, and an entire want of buoyancy and proper enjoyment of life." 2 The second stage presents the acute symptoms: ideas of per- secution, maniacal states. The third stage is a state of semi-stupor. Chartier, though admitting the existence of such a form, does not consider it as specific, and adheres to the opinion generally accepted in France " that most of the known forms of mental alienation may be observed coincidently with latent tuberculosis." 3 1 Chartier. De la phtisie et en particulier de la phtisie latente dans ses rapports avec les psychoses. These de Paris, 1899. 2 Clouston. Clinical Lectures on Mental Diseases, p. 510. 3 Chartier. Loc. cit. , p. 70. ETIOLOGY. 19 Symptomatically tuberculosis manifests itself most frequently by states of depression. 1 This is comparable to the abnormal sadness so often noticed in tubercular patients at the beginning of their affection . Whatever form they may assume, the mental disorders probably always indicate the same pathogenesis, and result from the action of the tubercular toxine upon the nervous system, also from the impairment of the general nutri- tion. Malignant tumors are sometimes accompanied by mental complications which usually assume the form of confusional insanity. 2 All the intoxications, exogenous or endogenous, are capable of determining the occurrence of mental dis- turbances; in practice some of these toxic agencies are encountered with especial frequency. Among the exogenous poisons the action of which is readily exerted upon the nervous system may be named, in the order of their clinical importance, alcohol; very far behind it morphine; and still less important car- bonic oxide, lead, mercury, cocaine, z etc. Among the intoxications of endogenous origin, or autointoxications, may be mentioned urcemia, myxedema, and acromegaly. 4 ' 1 Dufour et Rabaud. Bulletin de la Societe anatomique, Mars, 1S99. 2 Klippel. Les accidents nerveux du cancer. Archives gen. de Medecine, 1892. 3 Pellagra, which is probably a toxic disease, may be complicated by episodes of depression. Among the poisons which are apt to give rise to mental disturbances are to be mentioned further bella- donna, salicylic acid and its derivatives, the thyroid substance. (Marais, These, 1900.) ~ 4 Joffroy. Sur un cas d' acromegalic avec demence. Progres 20 MANUAL OF PSYCHIATRY. The importance attributed to the auto-intoxications is growing from day to day. We shall see that accord- ing to Kraepelin's ingenious conception general paresis is classed as a disease caused by auto-intoxication. Many cases of dementia prsecox seem to indicate an analogous pathogenesis. In a group closely related to the preceding are the disorders of nutrition, which may likewise be complicated by psychic disturbances. Gout occasions the occurrence of mental disorders which either precede or follow the attacks, or in some instances replace them, consti- tuting veritable metastases. 1 The association of psychic disturbances with diabetes has long since been noted by various authors. Before the time of Marchal cle Calvi glycosuria was generally thought to be the consequence of nervous or mental affections; this author has shown that the relation is reversed, that the latter states are the effect and not the cause. 2 Laudenheimer, 3 in a highly interesting and very medic, fevrier, 1898. — Brunet. Etat mental des acromegaliques. These de Paris, 1899. 1 Regis et Chevalier-Lavaure. Des auto-intoxications dans les maladies mentales. Congres de medecine mentale, 1894. — Seglas. Paper on the same subject. Ibid. — Mabille. L 'albuminuric chez les arthritiques et les auto-intoxications dans les maladies mentales. Ibid. — Von Solder. Des psychoses aigues dans la coprostase. Jahrb. f. Psych., 1898, Nos. 1 and 2. — Delle auto-intossicazioni nella Pato- genesi delle Neurosi et delle Psichosi. II Manicomio moderno, Vol. XIV, Xo. 3. 2 Cotard. Alienation mentale et diabete. — Bernard et Fere. Des troubles mentaux chez les diabetiques. Arch, de neurol., 1882, Vol. IV. 3 Rudolph Laudenheimer. Diabetes und Geistesstorung . Berlin, klin. Wochenschr., 1898, Nos. 21 and 24. ETIOLOGY. 21 thorough work, divided the cases in which diabetes and mental disorders coexist into four classes: (1) The diabetes and the mental disorders coexist without any etiological classes : (2) The diabetes is the consequence of the mental disease ; (3) The diabetes is the cause of the mental disease ; (4) The diabetes and the mental disorder are two effects of the same outside cause. Clinically the mental disorders of diabetes frequently assume the form of depression; there is, however, no absolute rule with regard to this. Aside from true diabetes, simple glycosuria is fre- quently encountered among the insane ; it is usually in- termittent, and follows the states of intense agitation. Overwork, inanition, cachectic diseases are, by reason of the general exhaustion and the nutritive disorders which they bring about, among the important factors in the etiology of insanity. Their most usual clinical expression is acute confusional insanity. 1 Chronic exhaustion manifests itself psychically in the neurasthenic states, the study of which belongs properly to the domain of neurology. Most organic lesions are capable of affecting the psychic functions. Ursemic insanity shows the importance of renal lesions in the etiology of mental diseases. The general vascular affections (arteritis, atheroma), through their interference with cerebral nutrition, are the prin- 1 Coulon. Du role des arterites dans la pathologie du sysVeme nerveux. Congres des medecins alienistes et neurologistes. Angers, 1898. 22 MANUAL OF PSYCHIATRY. cipal factors in the senile, alcoholic, and apoplectic dementias. Heart-disease l is frequent in the insane. The statis- tics of Strecker, 2 based upon 1000 autopsies performed in insane asylums, show that 61.7% of the men and 42. 7% of the women present cardiac lesions. These are quite frequently the consequence of the psychoses, especially of those which are accompanied by chronic excitement (Krafft-Ebing) . Sometimes also they pre- cede the mental trouble, and play an important part in the causation of the attack. Valvular insufficiencies and changes in the myocardium act either directly by giving rise to disorders of the cerebral circulation, or indirectly by bringing about renal and hepatic insufficiency. Everybody is acquainted with the changes of dis- position which sufferers from dental caries, 3 dyspepsia, or liver troubles 4 are subject to. Diseases of the stomach, intestine, and particularly those of the liver sometimes engender veritable psychoses. Such is also the case with affections of the generative organs, the importance of which, though of late much exaggerated, 1 Fischer. Ueber psychosen by Herzkrankheiten. Allg. Zeitschr. f. Psychiatrie, Vol. LIV, No. 6. — Pelgmann. Toxamische Delirien bei Herzkranken. Deutsche medic. Wochenschr. , 1899, No. 19. 2 Strecker. Virchow's Archive, Vol. 126. 3 Leopold-Levi. Hepatotoxhcmie nerveuse. Arch. gen. de med., mai, juin, juillet, 1897. — Cullerre. Hepatisme et psychoses. Arch, de neurol., now 1898. — Klippel. Insvffisance hcpatique dans les maladies mentales. Arch. gen. de med., 1892. 4 Poinsot. Creation et Jonctionnement du service dentaire a Vasile Sainte-Anne (asile clinique). Travaux du troisieme Congres den- taire international, huitieme section, Paris, 1900. ETIOLOGY. especially in the case of women, is none the less real. Similarly, functional disorders of these organs may be accompanied by disturbances in the psychical sphere. The slight mental troubles that often occur in the menstrual periods in some cases assume the proportions of veritable psychoses. The onset of menstruation in young women is also, at times, the origin of a more or less serious psychopathic process. Various mental troubles may make their appearance at this age, such as the periodic psychoses, dementia precox, hysterical attacks, etc. 1 The mental disorders accompanying visceral lesions were formerly called reflex insanities. It was supposed that an impression originating from the diseased organ and transmitted to the brain disturbed the psychic equilibrium and gave rise to insanity. Esquirol attached considerable importance to displacements of the trans- verse colon. In reality the pathogenesis of these cases is entirely different, and consists most likely in an auto- intoxication or an infection, the starting-point of which is in the diseased organ. The puerperal state 2 is a common cause of mental alienation. The puerperal psychoses do not form a homogeneous group, either from an etiological or from a clinical standpoint. The cause of the disorder may be either infection, or autointoxication, or profound anaemia following a hemorrhage. These diverse factors may act 1 Hegar. Zur Frage der sogenannten Menstrualpsy chosen. Allg. Zeitschr. f. Psychiatrie, Vol. LVIII, Nos. 2 and 3. 2 Castin. Des psychoses puerperales dans leurs rapports avec la degenerescence mentale. These, Paris, 1899. 24 MANUAL OF PSYCHIATRY. simultaneously. The clinical forms are most frequently primary mental confusion and dementia prsecox. Some- times the puerperal state merely brings to light a latent psychosis (epileptic, hysterical, or periodic insanity). In other words, there is no single puerperal insanity, but " insanities, or rather psychoses of the puerperum." * The puerperal psychoses proper are to be distinguished from the psychoses of pregnancy and from those of lactation. The first are the most frequent. The fol- lowing proportions are given by Aschaffenburg : 2 preg- nancy 22.7% ; puerperal state (childbirth) 57.6% ; lac- tation 17.7%. Traumatisms are often mentioned in the antecedents of insane patients. It is not always easy to determine the degree of their influence, for generally they precede very remotely the onset of the psychosis. Stolper 3 distinguishes three groups of traumatic psychoses: (1) Trauma-psychoses: the traumatism is the sole cause ; (2) Predisposition-trauma-psychoses : the traumatism merely brings out a pre-existing predisposition; (3) Trauma-predisposition-psychoses: the traumatism creates a predisposition, which some subsequent cause develops into a psychosis. In reality the predisposition is present in all forms of psychoses, traumatic or otherwise, so that the first two groups of Stolper fuse into one. 1 Ballet. Lecoiis cllniques sur Us ncvroses et les psychoses 3 Aschaffenburg. Ueber die klinischen Forrnen der Wochenbett- psychosen. Allg. Zeitschr. f. Psychiatrie, Vol. LVIII, Nos. 2 and 3. 3 Quoted by von Muralt. Katatonische Krankheitsbilder nach Kopfverletzungen. Allg. Zeitschr. f. Psychiatrie, Vol. LVII, No. 4. ETIOLOGY. 25 The traumatic psychoses * may present themselves under an infinite variety of clinical forms: catatonia (von Muralt), general paresis (Vallon), periodic insanity, neurasthenia, etc. Like the puerperal psychoses, the post-operative psy- choses have a complex pathogenesis. 2 They may result from the shock of the operation itself, from the anaemia following profuse hemorrhage, from an infection, or from a medicinal intoxication. One must also bear in mind the anxiety preceding the operation, which may attain considerable intensity, especially in degenerates (Joffroy). Clinically the post-operative psychoses assume va- rious forms, and do not constitute a special morbid entity. All the organic nervous diseases — tabes, multiple scle- rosis, focal cerebral lesions, etc. — and all the neuroses — epilepsy, hysteria, exophthalmic goitre, 3 chorea, 4 paral- ysis agitans, etc., — may be accompanied by mental disorders. Focal lesions, epilepsy, and hysteria, the psychic manifestations of which present special features, will form the respective subjects of special chapters. Congenital or acquired neurasthenia constitutes a fa- 1 Kaplan. Kopftrauma und Psychose. Transactions of the Psychiatrical Society of Berlin. Published in Centralblatt f. Nervenheilkunde und Psychiatrie, May 24, 1899. 2 Truelle. Etude critique sur les psychoses dites post-operatoires . These, Paris, 1898. — Picque. Du delire psychique post-operatoire. Ann medic, psychol. July and August, 1898. — Joffroy. Folie post-operatoire. Presse medicale, March 1898. 3 Joffroy. Des rapports de la folie et du goitre exophtalmique. Ann. med. psych., 1890. 4 Joffroy. De la folie choreique. Sem. medic, 1893. — Ladame. Troubles psychiques dans la choree degenerative. Arch, de Neur., 1900. 26 MANUAL OF PSYCHIATRY. vorable soil for the appearance of certain transient or permanent psychical derangements: obsessions, essen- tial anxiety, etc. Neurasthenic disorders are always associated with psychasthenic disorders, which may almost approach in intensity the depression of melan- cholia. Finally the neuralgias may, according to Krafft- Ebing, 1 engender true transient psychoses. Moral causes. — The laity is apt to exaggerate the importance of the moral factors, often mistaking the first symptoms of the disease for its cause. It is often said of an individual that jealousy or anger has driven him insane, while in reality the jealousy or the anger is the first sign of derangement in his case. One may apply to these passions what Fere justly said concern- ing love, "to become insane from love, one must have the love of an insane." The violent emotions do play a part, however, in the production of mental disorders, at least as adjuvant causes. I had under my care a precocious dement whose affection began several weeks after a fire in which she nearly perished. The influence of prolonged or repeated emotions is still more evident. Great national commotions and wars cause an increase in the number of the insane. It is true that the part played by the emotions is, in these cases, difficult to establish. Indeed a great many other causes co-operate with them. As the most important of these may be mentioned alcoholic excesses, stress, and privations. 1 Krafft-Ebing. Arbeiten, 1897, I, p. 81, and Allgem. Zeitschr. f. Psychiatrie, Vol. LVIII, Nos. 2 and 3. ETIOLOGY. 27 Prolonged anxiety, constant perplexity, also play a certain part in the etiology of the psychoses. These phenomena, seen chiefly in weak-minded individuals, are frequently in themselves the symptoms of an already established psychopathic state, and here again the dan- ger exists of mistaking the effect for the cause. Such is also the case with exaggerated religious prac- tices and with extreme sensibility, which also indicate a defective mental state. Isolation is said to produce mental disorders in pris- oners. It is not impossible that the abolition of all relations with their like and the absence of any occupa- tion capable of arousing the interest exercise an un- favorable influence upon the mental condition of pris- oners. But the action of these causes should not be overestimated, for it must not be lost sight of that most prisoners are congenitally abnormal, and that in some insanity has existed, unrecognized, before their im- prisonment. 1 Mental disorders may be communicated from one in- dividual to another. This constitutes mental contagion, and is to be attributed to suggestion (induced insanity of the Germans). Often the delusions are transmitted to only one indi- vidual; we then have the "delire a deux." This gen- erally occurs in the following manner: one individual 1 Kirn. Allg. Zeitschr. f. Psychiat., XVIII, 13— Riidin. Klinische Formen der Gej angniss-Psy chosen. Allg. Zeitschr. f. Psychiat., LVIII, Nos. 2 and 3. — Taty. Alicncs meconnus et condamncs. Congres de medecins alienistes et neurologistes, 10th Session, Marseille, 1899. — Pactet et Colin. Les alicncs devant la justice. Encyclopedic des aide-memoire. 2S MANUAL OF PSYCHIATRY. becomes insane and communicates his ideas to some member of his family or to one of his friends. The latter, who is always congenitally feeble-minded, accepts them without question, and sometimes even finds proof of them in his own hallucinations. His delusions are essentially the functions of the first indi- vidual; they undergo the same fluctuations, and dis- appear with the removal of the influence of the other patient. The mechanism is the same when the con- tagion spreads itself over a more or less numerous group of individuals, as, for instance, in psychoses of a religious type. In all the reported instances such epidemics become rapidly extinguished upon the re- moval of the influence of the leader. 1 1 Regis. De la folie a deux. These, Paris, 1880. — Marandon de Montyel. La folie a deux, Gaz. des Hopit., 1894. — Dervey. Remarks upon psychical contagion and infection. American Journ. of Insanity, Oct. 1899. — Ninas-Rodriguez. Epidemie de folie religieuse au Bresil. Ann. med. psych., May-June, 1898. — Falret. Etudes cliniques sur les maladies mentales et nerveuses, Paris, 1890, p. 545. — Michel Delines. Les emmures de Tornovo. Analyse d'un travail de Sikorski. Revue Scient., Sept. 3, 1898. CHAPTER II. SYMPTOMATOLOGY.— DISORDERS OF PERCEPTION. INSUFFICIENCY OF PERCEPTION.— ILLUSIONS.— HALLUCINATIONS. "The senses," says Jean Muller, " inform us of the various conditions of our body by the special sensa- tions transmitted through the sensory nerves. They also enable us to recognize the qualities and the changes of the bodies which surround us, inasmuch as these determine the particular state of the nerves." l The senses, in other words, are the means through which we obtain the knowledge of our own bodies and of the external world. For their proper functioning are necessary: (1) the reception of an internal or an external impression by a peripheral organ; (2) the transmission of this impres- sion to the brain; (3) its elaboration by the cortical cells, which transform it into a phenomenon of the consciousness: first sensation and then perception. Only the latter operation is of interest to the alienist. We shall study in succession: I. Insufficiency of perception; II. Illusions (inaccurate perceptions); III. Hallucinations (imaginary perceptions) . Halluci- 1 Jean Muller. Manuel de Physiologie. 29 30 MANUAL OF PSYCHIATRY. nations and illusions are often classed together under the name of psychosensory disorders. § 1. Insufficiency of Perception. Insufficiency of perception in its slightest degree may be met with in states of depression, at the onset of con- fusional states, etc. All external impressions are vague, uncertain, and strange. The patients complain that everything has changed in them and around them: objects and persons have no more their usual aspect; the sound of their own voice startles them. In a more marked degree of insufficiency external impressions no longer convey to the mind of the sub- ject any clear or precise idea; questions are either not understood at all, or understood only when they are very simple, brief, energetically put, and repeated several times. External stimulation, even the strong- est, is but vaguely perceived and often causes no re- action proportionate to its intensity or appropriate to its nature. Finally, complete paralysis of one or several forms of psychosensory activity is observed either in con- nection with profound disorders of consciousness, as in confusional insanity of the stuporous form, or by itself, as in hysterical amaurosis or deafness. Insufficiency of perception constitutes an important element of clouding of the consciousness, which will be considered later on. Its pathogenesis is closely connected with disorders of ideation. The normal act of perception really con- sists of two elements: (1) a sensory impression; (2) a SYMPTOMATOLOGY. 3 1 series of associations of ideas which enable the mind to recognize the impression and which almost always complete it and renders it more definite. If the second operation is not normally effected, the sensations remain vague and undecided, and there is insufficiency of per- ception. § 2. Illusions (Inaccurate Perceptions). An illusion may be defined as a perception which alters the qualities of the object perceived and pre- sents it to the consciousness in a form other than its real one. An individual who hears insulting words in the singing of birds or in the noise of carriage-wheels experiences an illusion. Illusions are of frequent occurrence in normal indi- viduals. There is no one to whom the folds of a cur- tain seen in semi-darkness did not appear to assume more or less fantastic shapes. But the mind, aided by the testimony of the other senses, recognizes the abnor- mal character of the image; the illusion is recognized as such. By the insane it is on the contrary taken as an exact perception and exercises a more or less marked influence upon all the intellectual functions. Illusions affect all the senses and present, in the case of each, features analogous to those of hallucina- tions; I shall therefore not describe them here. I shall say but a few words concerning illusions of sight which present certain peculiarities. Illusions of sight may occur in most of the psychoses, but are chiefly found in the toxic psychoses and in the infectious deliria. When these illusions are pertaining 32 MANUAL OF PSYCHIATRY. to persons they are known as "false recognitions." Many insane individuals see among their fellow patients or among the staff of employees of the institution their relatives or friends. This form of illusions sometimes attains such completeness that the subject may, while at the hospital, believe himself to be at his home. Illusions are very apt to occur in the midst of vague impressions: those of hearing in the presence of con- fusing noises, and those of sight in semi-darkness. Like incomplete perceptions, inaccurate perceptions or illusions are the consequence of a disorder of idea- tion; abnormal associations replace the normal ones, which are absent, and complete the image, altering it at the same time. § 3. Hallucinations (Imaginary Perceptions). " A person who has an inmost conviction of a sensa- tion actually perceived, when no external object capable of exciting such sensation is within reach of the senses, is in a state of hallucination" (Esquirol). "By hallucinations are understood subjective sensory images which are projected outwardly and which in that way acquire objectivity and reality" (Griesinger) . "'A hallucination is a perception without an object" (Ball). These three definitions are essentially identical. That of Ball appears to me to be the best on account of its conciseness. Hallucinations may affect any of the senses. There are therefore as many varieties of hallucinations as there are senses. SYMPTOMATOLOGY. 33 Some properties are common to all varieties of hal- lucinations, others are peculiar to each variety. A. PROPERTIES COMMON TO ALL VARIETIES OF HALLUCINATIONS. Hallucinations exercise an influence upon the psychic personality of the patient, which varies with the sub- ject, the nature of the disease, and the different stages of the same disease. In a general way it may be stated that the more acute the character of the mental disorder (acute psychoses, periods of exacerbation in chronic psychoses) and the less enfeebled the intellectual activity, the more marked is the influence of the hallucinations. In accordance with this rule, the correctness of which is clinically demonstrated, hallucinations abate in their influence as the acute stage of the psychosis subsides — either when the patient enters upon con- valence, or when he lapses into dementia; under such conditions they may persist for a greater or lesser length of time without exercising any influence upon the patient's emotions or actions. The influence of hallucinations upon the psychic func- tions. — Attention. — Hallucinations force themselves upon the attention of the patient. In the case of hallucina- tions of hearing, for instance, he is compelled to listen to them, sometimes in spite of himself, no matter what their degree of clearness is, — whether they consist of distinctly spoken words or phrases, or of a scarcely perceptible murmur. The patient is sometimes conscious of the tyrannical dominating power to which he is subjected. "I am 34 MANUAL OF PSYCHIATRY. - forced to listen to them/' said one of these unfortu- nates; "when they (his persecutors) get at me I can do no work, cannot follow any conversation, / am wholly in their power." Hallucinations thus resemble the imperative ideas and the autochtonous ideas which we shall study later on. Judgment. — Hallucinations may coexist with sound judgment and be recognized by the patient as a patho- logical phenomenon. They are then called conscious hallucinations. Such instances are not very rare and consist chiefly of hallucinations of sight. A celebrated case is that of Nicolai, the bookseller. "The visions began in 1791, after an omission of a bloodletting and an application of leeches which he underwent habitually for hemorrhoids. All of a sudden, following a strong emotion, he saw before him the form of a dead person, and on the same day diverse other figures passed before his eyes. This repeated itself on numerous occasions. "The visions were involuntary and he was unable to form an image of any person at will. Most of the time, also, the phantoms were those of persons unknown to him. They appeared during the day as well as during the night, assuming the colors of the natural objects, though they were somewhat paler. After a few days they began also to speak. One month after the onset of this affection, leeches were applied; on the same day the figures became more hazy and less mobile. They disappeared finally after Nicolai had for some time seen only certain portions of some of them.' 7 1 1 Jean Muller. hoc cit. SYMPTOMATOLOGY. 35 Some individuals possess the power of producing their hallucinations at will. Goethe had that power. "As I shut my eyes," he said, "and lower my head I figure to myself a flower in the center of my visual organ; this flower does not retain for an instant its original form; it forthwith rearranges itself and from its interior appear other flow r ers with multicolored or sometimes green petals; they are not natural flowers, but fantastic, though regular, figures like the rosettes of the sculptors. It is impossible for me to fix the creation, but it lasts as long as I desire without increasing or diminishing." 1 In the great majority of cases the judgment, itself dis- ordered, is unable to correct the psychosensory error: the hallucination is taken for a true perception. Though sometimes in the beginning of the disease the subject experiences some doubts, this transitory incertitude is soon replaced by a blind belief in the imaginary perception. "We observe/' says Wernicke, "that the reality of the hallucinations is maintained against the testimony of all the other senses, and that the patient resorts to the most fantastic explanations, rather than admit any doubt as to the accuracy of his perception." 2 An individual, alone in the open field, hears a voice calling him a thief. He will invent the most absurd hypotheses rather than believe himself a victim of a pathological disorder. Certain patients, chiefly the weak-minded and the demented, accept their hallucinations without inquiring 1 Jean Muller. Loc cit. 2 Wernicke. Grundriss der Psychiatrie, p. 126. 36 MANUAL OF PSYCHIATRY. as to their origin or mechanism; others on the con- trary elaborate explanations which vary with the nature of the malady, the degree of the patient's educa- tion and intelligence, and the current ideas of the times. In the middle ages the psychosensory disorders of the insane were often attributed to diabolic intervention, and this not only by the patient himself but also by his friends. The patients of our own times mostly resort for explanations to the great modern inventions (electric currents, telephone, X-rays, wireless telegraphy, etc.). Some fancy to themselves apparatus or imagi- nary forces. One patient attributed his disturbances of general sensibility to a " magneto-electro-psychologic" current. Another received the visions from a "theolo- gico-celestial projector." Affectivity . — Hallucinations are sometimes agreeable, at other times painful, and occasionally, chiefly in dements, indifferent. In the first case their outward manifestations are an appearance of satisfaction, an expression of happiness, and sometimes ecstatic attitudes. In the second case, which is the most frequent, the patients become sad, gloomy, or, on the contrary, agitated and violent, a prey to anxiety or anger. The two kinds of hallucinations, agreeable and pain- ful, are occasionally encountered in the same subject. Sometimes they follow each other without any regular order and are coupled with a variable disposition and incoherent delusions, as in maniacs and in general paretics; at other times they follow each other some- what systematically — the painful hallucinations are combated by the agreeable ones. The patients SYMPTOMATOLOGY. 37 often speak of their persecutors, who insult, threaten, and abuse them, and of their defenders who con- sole them, reassure them, and repair the damage done by the former. A persecuted patient heard a voice call her "a slut"; immediately another voice responded, "He lies; she is a brave woman." Some patients tell of their limbs being smashed and their viscera extracted every night, but that nevertheless they are sound and safe when they arise, thanks to the good offices of their defenders, who properly replace everything. These two sets of hallucinations con- stitute what the patients sometimes call the attack and the defense. The indifferent hallucinations are of but little interest. They are met with at the terminal periods of the pro- cesses of deterioration, and also at the beginning of convalescence in the acute psychoses. In the latter case they rapidly become conscious hallucinations and finally disappear. - Reactions. — The influence of hallucinations upon the will depends upon the state of the judgment and of the affect ivity. If the judgment is sound, if the hallucina- tions are looked upon as pathological phenomena, they give rise to no reaction; and the same is the case when they make no impression upon the emotions. But when they are accepted by the patient as real perceptions and influence strongly the emotional state, hallucinations, on the contrary, govern the will to a very considerable extent and prompt the patient to defend himself against the ill-treatment of which he believes himself to be the object or to obey the com- mands which are given him (imperative hallucinations). 38 MANUAL OF PSYCHIATRY. Hence the frequency of violent and criminal acts com- mitted by the insane, and the well-known axiom in psychiatry according to which all subjects of hallucina- tions are dangerous patients. The reactions caused by hallucinations are often abrupt, unreasonable, and of an impulsive character, especially in the feeble-minded and in patients with profound clouding of consciousness (delirium tremens, epileptic delirium). But they may also show all the evidences of careful premeditation. Certain perse- cuted patients, exasperated by their painful hallucina- tions, prepare their vengeance with infinite precau- tions. The influence of hallucinations upon the will is often so powerful that nothing can combat it, neither the sense of duty, nor the love of family, nor even the instinct of self-preservation. A patient passing near a river heard a voice tell him: " Throw yourself into the water." He obeyed without hesitation, and to justify himself declared simply: "They told me to do it; I was forced to obey." Combined hallucinations. — Sometimes hallucinations affect but one sense. Such are the hallucinations of hearing at the beginning of systematized deliria. Gener- ally, however, the pathological disorder affects several senses, the different hallucinations either following one another, or existing together without any correlation, or combining themselves and producing complex scenes either of a fantastic aspect or analogous to real life. In the latter case they bear the name of combined hallucina- tions. The patient sees the imaginary persons, hears them speak, feels the blows that they inflict upon him, SYMPTOMATOLOGY. 39 makes efforts to reject the poisonous substances which they force into his mouth, etc. This state, closely re- lated to dreaming, is always accompanied with marked clouding of the intellect. Diagnosis of hallucinations. — Two possibilities may present themselves: (1) The patient directly informs the physician about his •condition; (2) He gives no information whatever, either because of his reticence or because of his intellectual obtuseness. In the first case the diagnosis of hallucinations is gen- erally easy. It is necessary, however, to ascertain that the pathological phenomenon is really a hallucination, and not an illusion; in other words, that it is a percep- tion without an object, and not an inaccurate percep- tion. Only a detailed examination of the circumstances under which the phenomenon shows itself will prevent the error; it is very difficult indeed, when a subject hears himself being called a thief in the midst of thousands of street noises, to decide whether he experiences a hallu- cination or an illusion. The certainty is, on the other hand, much greater when the morbid perception occurs in absolute silence, as during the night, for instance. In the second case the diagnosis must be made with- out the assistance of the patient, or even in spite of his denials. It must be based only upon the patient's atti- tudes, movements, and at times upon the means of defense which he resorts to and which vary according to the sense affected. The ear turned for some time in a certain direction, the eyes fixed or following a definite line without there being any real object to attract them, the ears stuffed with foreign bodies, evidences of strong emotions, an expression of fear, etc., lead to the pre- 40 MANUAL OF PSYCHIATRY. sumption of the existence of hallucinations. I say pre- sumption because the external signs do not enable us to establish with certainty the patient's state of conscious- ness. Over-refined psychological analyses are to be mistrusted if one is to avoid unwarranted conclusions which would render the diagnosis and prognosis faulty. Relations between hallucinations and other mental disorders. — What position do hallucinations occupy in the genesis of the psychoses? Are they primary or secondary? It is not impossible that at times, notably in the in- toxications and in cases of localized lesion, hallucina- tions appear first and are the cause of the other mental disturbances which follow. In practice, however, such cases occur but rarely. A careful and complete history almost always shows that the hallucinations are pre- ceded by other symptoms: depression, intellectual ob- tuseness, clouding of consciousness, delusions, etc. Indeed it is difficult to conceive of one or more hal- lucinations appearing in an individual free from all other mental trouble, without their being at once cor- rected by the judgment aided by the other senses. On the other hand it is quite intelligible that imaginary per- ceptions may exercise an influence upon the attention, the emotions, the judgment, and the will, if they are but the reflection or the realization of the patient's pre- occupations and morbid ideas, that is to say, if they are secondary. The melancholiac who believes himself guilty of a crime sees and hears the police officers who are coming to arrest him. The persecuted patient who believes himself to be exposed to the malevolence of his imaginary enemies hears their voices insulting him. SYMPTOMATOLOGY. 41 The general paretic with pleasing and expansive delu- sions experiences pleasant sensations. Hallucinations are, then, the expression, and not the cause, of delusions; and that is why they harmonize so perfectly with the mental state of the subject. Some alienists l have described a hallucinatory de- lirium as a distinct morbid entity the essential features of which are the multiplicity and the primary character of the hallucinations. If the idea which I attempted to expose above is correct, hallucinations, never or almost never being primary, cannot form the essentialand ex- clusive feature of an affection, and hallucinatory delirium cannot retain its autonomy. Therefore most authors classify such cases with confusional insanity, general paresis, dementia prsecox, and the toxic psychoses. General etiology- of hallucinations. — On this subject we possess but very incomplete information. Hallucinations appear readily in states of impaired consciousness, as epileptic delirium and the toxic psy- choses. It is to the enfeeblement of consciousness that the hallucinations induced by hypnotics are to be attrib- uted; these hallucinations precede the sleep in certain nervous subjects and are most frequently of the con- scious type. Hallucinations are very apt to appear in the absence of real sensations, — those of hearing during silence and those of vision in darkness. This explains why isolation in prison-cells, practiced in penitentiaries, predisposes to hallucinatory psychoses (Kirn). In some instances hallucinations are produced in a 1 Farnarier. La psychose liaUucinatoire, Paris, 1S99. 42 MANUAL OF PSYCHIATRY. somewhat automatic manner, at the occasion of some definite impression. One patient felt a taste of sul- phur in his mouth whenever the name of one of his per- secutors was uttered in his presence. Such hallucina- tions have been described by Kahlbaum under the name of reflex hallucinations. Hallucinations may depend to a certain extent upon a peripheral excitation either of the sensory organ itself or of the conducting nerve. They are in such cases frequently unilateral. "Max Busch has brought about a notable improvement in the mental condition of a patient who had auditory hallucinations which were most marked on the left side, by treating his otitis media with perforation of the drum membrane, which he had contracted during childhood." x Visual hallu- cinations have been observed to appear as the result of ocular lesions, such as cataract, and to disappear under appropriate treatment. These peripheral lesions are, so to speak, but a pretext for the hallucinations, and are not to be considered as their true cause. The cause is to be looked for in the special state of morbid irritability of the centers of perception which causes them to react by hallucinatory phenomena to abnormal peripheral excitation. 2 Peripheral hallucinations are very analogous to Liep- mann's phenomenon: if in a convalescing alcoholic- slight pressure is made upon the eyeballs, hallucina- 1 Quoted by Legay. Essai sur les rapports de Vorgane auditif avec les hallucinations de Vouie. These de Paris, 1898, p. 25. 2 Joffroy. Les hallucinations unilaterales. Arch, de neurol., 1896, No. 2. — Mariani. Un cas d' hallucination unilaterale. Riforma medica, 1899, Nos. 30 and 31. SYMPTOMATOLOGY. 43 tions are sometimes induced, even when the subject does not any more experience them spontaneously. The peripheral excitation transmits to the brain nothing but a nervous discharge the clinical expression of which is the hallucination. The fact that a great many patients present very grave and old standing lesions of the sensory organs without having any hallu- cinations is also evidence of the fact that these affec- tions are of but secondary importance in the causation of psychosensory disorders. Finally, hallucinations may be induced by sugges- tion. Sometimes it suffices merely to fix the attention of the patient upon a certain point for him to discover imaginary objects, persons, or forms. Such is fre- quently the case with the intoxicated, notably alcoholics and cocainomamacs, also with certain dements. In an observation kindly communicated to me by Thivet, a patient read whole words upon a blank sur- face that was presented to him. B. SPECIAL FEATURES OF EACH VARIETY OF HALLU- CINATIONS. Hallucinations of hearing. — In pathological states, as in the normal state, auditory sensations occupy a posi- tion of primary importance among the psychic func- tions; thus, of all the hallucinations those of hearing are clinically the most frequent and the most important. Seglas x classifies them in three categories: "The 1 Lecons diniques sur les maladies mentales et nerveuses, p. 5. — Pathogenie et physiologie pathologique de V hallucination de Vouie. Congres des medecins alienistes et neurologistes, 1897. 44 MANUAL OF PSYCHIATRY. elementary auditory hallucinations, consisting of simple sounds; the common auditory hallucinations, con- sisting of sounds referable to definite objects; and finally verbal auditory hallucinations, consisting of words representing ideas." Wernicke 1 combines the first two categories under the name of akoasms, and designates the third, the only one that seems to him to merit separate considera- tion, by the name of phonemes. Akoasms comprise imaginary noises of a variable nature, such as buzzing, whistling, screaming, groan- ings, ringing of bells, explosions of firearms, etc. Their clinical significance is the same as that of hallucinations in general, and their influence upon the mind depends upon their interpretation by the patient. Phonemes (the verbal auditory hallucinations of Seglas) have on the contrary a special significance, in- asmuch as they consist of " words representing ideas.". Their influence is much more direct and much more powerful than that of akoasms. Their content varies from isolated words to the most complicated discourses. Sometimes the words or phrases are pronounced indistinctly, resembling a faint murmur; at other times they are perceived with remarkable clearness. "It seems to me," patients often say, "that somebocty is speaking very near me . . . I hear my enemies as well as I hear you." This dis- tinctness largely accounts for their being accepted as real voices, and explains partly the remarkable influence of auditory hallucinations. x Loc. cit., p. 189. SYMPTOMATOLOGY. 45 The " invisible ones/' as the patients often call the imaginary voices, are sometimes localized with extraor- dinary precision. "The insane manifest a power of localization not encountered in other than patho- logical states." 1 The distance at which they believe they hear the voices is very variable; the voices may be very close by or, on the contrary, hundreds of miles away. Many patients hold the persons that are around them responsible for the hallucinations; thus are explained some of the sudden assaults often, com- mitted by such patients. Others ascribe their hallu- cinations to inanimate objects. One patient accused her needle, another her stockings. Still others lay the blame upon invisible instruments which are used by their enemies (phonographs, telephones, megaphones, etc.). Like all other hallucinations, those of hearing vary with the nature of the mental trouble: sad in the painful states, agreeable and cheerful in the expansive states. Usually the names by which the patients designate the " invisible ones" are not very choice ones, consisting chiefly of profane or even filthy expres- sions. Unpleasant hallucinations may alternate with the agreeable ones in the manner of attack and defense, as has already been stated. Sometimes each of the two varieties of hallucinations is perceived by only one ear. The voices may repeat the thoughts of the patient, even before he has a chance to express them. "They know before I do what reply I wish to make," said 1 Wernicke. Loc. cit., p. 205. 46 - MANUAL OF PSYCHIATRY. one such patient. Another said: "'When I read they read at the same time and repeat every word." Many complain that their thoughts are stolen from them. 1 Quite often the voices create neologisms the meaning of which may remain absolute^ enigmatical to the patient himself, or to which he may attribute a signifi- cance which harmonizes with his psychical state. The timbre of the voices is very variable. In some cases the patient always perceives one and the same voice; but more frequently many voices are heard: voices of men, women, and children, which are some- times unknown to the patient, at other times familiar and enabling him to establish the identity of his perse- cutors. Although they are encountered in a great many mental affections, acute and chronic, hallucinations of hearing, if they constitute a prominent feature by reason of their multiplicit}^, distinctness, or intensity, usually point to a grave prognosis. Their occurrence in an acute psychosis often forebodes a particularly long duration of the disease. Hallucinations of sight. — Hallucinations of sight chiefly occur in toxic and febrile deliria and in certain neuroses (hysteria, epilepsy, chorea). They vary greatly in distinctness. At times they are so clear that the patient is able to make a sketch of them; often they are, on the contrary, vague and uncertain. Like the voices, the visions are apt to be taken for 1 Bechterew. Ueber das Horen der eigcnen Gedanken. Arch. f. Psychiatrie, Vol. XXX. SYMPTOMATOLOGY. 47 reality by the subject; he seeks to remove them, to shun them, or on the contrary to seize them. They are in such cases coupled with a more or less marked cloud- ing of the intellect. Many patients, on the contrary, consider their hal- lucinations as artificial phenomena. The more con- scious and the clearer in mind the patient is, the more apt he is to recognize the difference between the real world and his visions, because, with the exception of the cases in which the consciousness is profoundly disordered, visual hallucinations "seldom bear the appearance of reality.' 7 1 They lack the proper qualities of normal visual sensations: perspective, clearness of contour, variety of tints, etc. Often the morbid image appears in a single plane, hazy in outline, and grayish in color. It is therefore not surprising that, not possessing the attributes of true perceptions, visual hallucinations are often not taken for reality, and do not exercise upon the mind of the patient the same degree of influence as do the phonemes. Some patients consider their hallucinations as shadows or images which they are made to see artificially by means of projecting apparatus, electric currents, etc. Others attribute them to the pernicious action of poisons which their enemies make them absorb. Visual hallucinations may take the form, though rarely, of verbal hallucinations of vision. The patients see words and phrases written on tables, walls, etc. A subject of choreic insanity whom I have observed in Joffrov's clinic saw hor own name written on hor 1 Wernicke. Loc. cit,, p. 194. 48 MANUAL OF PSYCHIATRY. apron. Everybody is familiar with the famous words Mem, mene, tekel, upharsin, which the guests saw ap- pear upon the Avail at Belshazzar's feast. Hallucinations of taste and smell. — The senses of taste and smell are as closely associated in pathological states as they are in the normal state. Therefore hallucinations of these senses are usually considered together. Their clinical significance varies, depending upon whether they coexist with psychic and somatic dis- orders of an acute nature, or they appear in the course of a chronic psychosis. In the first case they often result from the dryness and the inflammation of the nasal and buccal mucous membranes or glands. They disappear with the dis- turbances of these glands, and they may be modified very favorably by appropriate treatment. Their im- portance with regard to the prognosis in such cases is very slight. It is altogether different in the second case, when the} 7 supervene independently of the above causes in the course of chronic affections. They almost always indicate a profound alteration of the personality and the progress of the mental disorder towards dementia. Hallucinations of taste and smell are mostly unpleas- ant. The patients complain of nauseating odors; putrid emanations are blown towards them; they are made to eat fecal matter; poisons are poured into their mouth, etc. They make use of certain means of defense, such as spitting, stuffing the nostrils with cotton or paper, and, what constitutes a very grave symptom, refusal of food. SYMPTOMATOLOGY. 49 Hallucinations of touch, of the thermal sense, and of the sense of pain. — These are often placed in a single group under the name of hallucinations of general sensibility. Hallucinations of touch are frequent in certain toxic psychoses (delirium tremens, cocaine delirium), and in chronic systematized deliria. The patients feel the breath of somebody or the contact with something ; they feel as though spiders were crawling upon their bodies, or they may have a sensation of being bound in an entangled mass of cords. Closely related to the above are the hallucinations of the genital sense, which are encountered in neuroses, chiefly hysteria, in mania, and in a great many other acute and chronic psychoses. They consist of either painful or voluptuous imaginary sensations. When they co-exist with perfect mental lucidity they generally indicate a very grave prognosis. Hallucinations of the thermal sense and of the sense of pain are a feature of chronic systematized deliria. The patients complain of being burned alive, that their body is being pierced with a red-hot iron, that they are being thrown off from their chair, that they are made to experience shocks like those of electric discharges, etc. Motor hallucinations. — A motor hallucination may be defined as an imaginary perception of movement. It constitutes a disorder of that kind of sensibility which has been designated by the term muscular sense. Analogous phenomena are encountered in normal individuals: the sensation of heaviness or of lightness of the limbs, which we experience during sleep, are justly attributed by Beaunis * to disturbances of the mus- 1 Les sensations internes, 1889, Paris, F. Alcan. 50 MANUAL OF PSYCHIATRY. cular sense; the illusions referred to an amputated limb are often accompanied by motor hallucinations. Motor hallucinations are frequent among the insane. Some feel themselves being raised from their bed, being shaken continually against their will, etc. Others, like the mediaeval sorcerers, imagine themselves flying in the air. By a well-known psychological process the sensation tends to transform itself into an act, the motor image into a movement. The motor hallucination becomes an impulse. The patient feels with astonishment that his limbs, his tongue, or his mouth become the seat of movements in which his will takes no part. A patient of Krishabers, for instance, felt his legs "move as though endowed with a power other than that of his own will." Many of the persecuted or mystic patients affirm that they have been transformed into automatons, and that God or their enemies, as the case may be, can make them go and act as they wish. There is a certain form of motor hallucinations, which deserves particular attention by reason of its frequency, its clinical importance, and its high psy- chological interest; these are the verbal motor hallu- cinations which have been admirably described by Seglas. 1 As their name indicates, they affect the func- tion of speech. The patient is conscious of involuntary movements of his tongue and lips, identical with those which produce articulation of words. The sensation may exist alone or it may acquire such intensity that 1 Lecons cliniques. Also Les troubles du langage chez les alienes. (Bibliotheque Charcot-Debove.) SYMPTOMATOLOGY. 51 it is transformed into actual motion, and the patient begins to speak in spite of himself. Often the patho- logical movements are scarcely apparent, being limited to an inaudible whisper. Sometimes the impulse is so strong that it results in loud talking or screaming. The remarks made by the patient in such a case may be entirely discordant with his true sentiments. In this way such patients may unintentionally insult their relatives, making use of obscene language, blasphemies, etc. At other times the very thoughts of the patient are spoken out in spite of himself. Pierr acini has termed this phenomenon "the escape of thought. " (Quoted by Seglas). Verbal motor hallucinations exercise upon the function of speech, even in those cases in which they do not reach the stage of actual articulatory movements, so powerful an inhibitory influence that the subject be- comes totally unable to speak. This is in perfect accord with the observation of Strieker, who found that two verbal motor images cannot exist at the same time. Already occupied by the hallucinatory motor image, the consciousness remains closed to normal motor images. Verbal motor hallucinations are thus a cause of mutism. Graphic motor hallucinations affect written speech. "The graphic image then comes into play, and in con- sequence of the morbid irritability of the special cortical centre for written speech the patient has the exact per- ception of a word with the aid of the representations of the co-ordinate movements which would accompany it if he were really writing the word," l 1 Seglas. Les troubles du langage, p. 246. 52 MANUAL OF PSYCHIATRY. / AYhen this morbid irritation attains a certain degree of intensity the hallucination becomes a graphic impulse and gives rise to automatic writing, which is often met with in the "writing mediums." The interpretation of motor hallucinations varies in different patients. Some complain that their enemies govern their tongues by means of invisible wires. Others, feeling themselves no longer masters of their own or- gans, are naturally led to think that a strange personality has become established alongside of themselves. Some of the "possessed" of the mediaeval times undoubtedly had motor hallucinations. Motor hallucinations generally involve a grave prog- nosis. They indicate an already advanced disaggre- gation of the personality. Therefore they are chiefly encountered in the chronic psychoses; they may appear, however, in certain acute psychoses, such as melan- cholia (Seglas) and alcoholic systematized delirium (Vallon, Cololian). 1 Theories of hallucinations. — I shall but mention the so-called psychological theory, according to which hallucinations are supposed to be a phenomenon purely of ideation. Physicians and physiologists have long ago abandoned this theory. But though all the authors to-day admit the existence of a material pathological process as the foundation of hallucinations, they are far from being in accord as to its nature and as to its seat. Jean Muller is of the opinion that hallucinations are 1 Cololian. Les hallucinations psycho-motrices verbales dans Valcoolisme. Arch, de Neurol., Nov. 1899. SYMPTOMATOLOGY. 53 the consequence of an abnormal irritation of the periphe- ral sensory organ. According to Meynert they result from the automatic activity of the subcortical cerebral centers, which are no longer inhibited by the cerebral cortex as they are in the normal state. The primary cause of hallucinations would thus be a suppression of the inhibitory power of the cortex, which is one of the manifestations of cortical paralysis. The hallucination is then the consequence of a supremacy of the inferior cerebral functions over the higher ones. Finally, according to Tambourini, whose opinion is to-day the most widely accepted one, hallucinations are produced by the automatic activity of a psycho- sensory projection-center. Under what conditions does the automatism of the projection-center come into play? Is it under the influence of direct irritation resulting, for instance, from a tumor or from a circumscribed patch of men- ingitis localized exactly at this center? Such cases occur. Serieux 1 has observed verbal motor hallucinations in a general paretic in whose case the autopsy showed a predominance of the lesions of meningo-encephalitis at the level of the lower portion of the left third frontal convolution. The lesion must not, however, be a too destructive one. "Indeed, for a center to be able to produce hallucinations, it is necessary that conditions of integrity be preserved sufficient to permit its activity " (Joffroy). 2 1 Sur un cas d' hallucination motrice verbale chez une paralytique generate. Bull, de la soc. de m£d. merit, de Belgique, 1894. 2 Les hallucinations unilaterales. — Siebert has also reported a case 54 MANUAL OF PSYCHIATRY. Most frequently, however, the center of projection is not the seat of any demonstrable lesion. It seems, then, that in most cases the hallucinations are the conse- quence, not of a direct irritation of the psychosensory center itself, but rather of an indirect irritation coming from another portion of the cortex. This explains why hallucinations are always a secondary phenomenon, and why they are but an expression, a reflection of the pathological preoccupations of the patient. Wernicke has conceived a very ingenious theory of hallucinations, founded upon his general hypothesis of sejunction. By this term he designates a temporary or permanent interruption of the paths followed nor- mally by a nervous impulse. This impulse cannot pass on freely, and accumulates above the point of the lesion like the water in a river above a dam. When this accumulation occurs in a psychosensory projection- center it determines there a state of abnormal irrita- tion of which the clinical expression is a hallucination. in which very pronounced hallucinations of the sense of smell persisted for a long time and subsequently disappeared by degrees. At the autopsy the hippocampus was found to be destroyed by a tumor. The author supposes that the hallucinations were caused by irritation of the center in question by the growth, and that they did not cease until this center was destroyed. (Monatschr. fur Psych, u. Neurol., Vol. VI.) CHAPTER III. SYMPTOMATOLOGY {Continued). CONSCIOUSNESS. —MEMORY. — VOLUNTARY ASSOCIA- TIONS OF IDEAS.— A TTENTION.—A UTOMA TIC ASSO- CIATIONS OF IDEAS— JUDGMENT. § 1. Disorders of Consciousness. The consciousness may be weakened, resulting in unconsciousness or in clouding of consciousness; or exaggerated, causing hyperconsciousness. Weakening of consciousness. — Unconsciousness exists physiologically in dreamless sleep, and pathologically in coma and in complete stupor. Clouding of consciousness represents the fundamental element of many psychoses. It is always coupled with more or less complete disorientation. A complete orientation implies the integrity of the following three notions: 1. The notion concerning our own personality (auto- psychic orientation of Wernicke) ; 2. The notion concerning the external world (allo- psychic orientation of the same author); 3. The notion of time. These three notions may disappear together or singly. We shall see later that in certain affections, 55 56 MANUAL OF PSYCHIATRY. notably in delirium tremens, the orientation of time and place is lost, while that of personality remains intact. The patient is ignorant of the fact that he is in a hospital ward, does not appreciate his surroundings, and cannot give even approximately the real date. But he knows that he is Mr. X., following such and such an occupation, so and so many years old, born on such and such a day, etc. Allopsychic disorientation, or loss of the notion of the external world, is often coupled with many hallu- cinations. Some authors see in the two symptoms a causative relation; the hallucinations transport the patient to an imaginary world, thus making him lose the notion of the real world. Experience does not bear out this hypothesis: 1) because the orientation may be perfectly preserved in spite of intense and unceasing hallucinations; 2) because, inversely , it may be pro- foundly disordered without there being hallucinations of any kind; 3) because in most of the cases in which these two symptoms are associated the disorientation precedes the psychosensory disturbances. Influence of enfeeblement of consciousness upon the emotional state and upon the reactions. — Unconscious- ness and clouding of consciousness find expression, in the emotional sphere, in indifference and dullness; and, in the psychomotor sphere, in aboulia which in extreme cases may amount to complete inaction. If complicated by symptoms of excitement, hallu- cinations and illusions, delusions, or anxiety, clouding of consciousness is accompanied by emotional phenom- ena and reactions characteristic of each of these states. It is important to remember above all that the disorder SYMPTOMATOLOGY. 57 of consciousness may impart to the reactions of the patient a more or less impulsive character; hence their brutal and sometimes ferocious nature. Diagnosis of enfeeblement of consciousness. — Uncon- sciousness is generally apparent from the absolute indifference of the subject who fails to react even to the strongest stimulation. However, it is necessary to exercise great caution in many cases. We shall see later on that certain patients, the catatonics, present all the appearances of unconsciousness and may never- theless preserve a perfect lucidity; the disorder of con- sciousness is here only a seeming one. Quite often one is obliged to wait before making a decision; when the attack passes off, the patient himself may tell of his former condition, either declaring that he has no recol- lection of what has passed during the attack, — in which case the unconsciousness was real, — or explaining that, though receiving the external impressions, he was unable to react, — in which case the unconsciousness was but a seeming one. Clouding of consciousness is determined by putting to the subject a series of questions concerning his age, his occupation, the date, the surroundings, and the persons about him. States of obscuration. — By this term are designated those pathological states in which the disorder of con- sciousness is the dominant feature. States of obscura- tion vary greatly in their aspect, and probably also in their nature. All, however, possess one feature in common: they leave behind them an almost complete amnesia for the occurrences that have taken place during their entire duration. But the state of con- 58 MANUAL OF PSYCHIATRY. sciousness at the time of the attack itself is very diffi- cult to determine, and probably varies greatly. Often patients afflicted with violent delirium have but an extremely confused notion of their surroundings, and their acts bear the character of complete automa- tism. Such are cases of epileptic delirium. Others, on the contrary, perform complicated acts, such, for instance, as are involved in a long voyage, in a sober and reasonable manner and without attracting anybody's attention; and still they may have no sub- sequent recollection of these acts. It can scarcely be assumed that in these two cases the disorders of consciousness are essentially identical. Exaggeration of consciousness. — Morselli distin- guishes two kinds of hyperconsciousness : " Hyper- consciousness with diffuse introspection, when the self- consciousness is referred to organic phenomena, giving rise to illusions and hallucinations of general sensibility and of ccensesthesia in melancholiacs, hypochondriacs, and paranoiacs; and hyperconsciousness with con- centrated introspection, when representations are per- ceived and emotions experienced with an abnormal intensity: hence the ecstasy of spontaneous or induced (hypnotic) hallucinatory states." 1 Generally hypercon- sciousness is but partial: certain sensations or certain representations absorb the conscious psychic activity to the partial or complete exclusion of others. 1 Morselli. Loc cit., p. 754. SYMPTOMATOLOGY. 59 § 2. Disorders of Memory. An act of memory comprises three distinct operations : 1. The fixation of a representation; 2. Its conservation; 3. Its revival, that is to say its reappearance in the field of consciousness. These may be disordered together or singly; hence the three kinds of amnesia: A. Amnesia by default of fixation (or simply amnesia of fixation), also known as anterograde amnesia ; B. Amnesia of conservation; C. Amnesia of reproduction. The latter two affect impressions previously acquired and constitute retrograde amnesia; there are there- fore two varieties of retrograde amnesia: 1) by default of conservation, and 2) by default of reproduction. A. Amnesia of fixation. Anterograde Amnesia. — The power of fixation (Merkjdhigkeit of German authors) is dependent upon the distinctness of the perceptions. Therefore all conditions in which the perceptions are vague and uncertain are accompanied by a more or less marked amnesia of fixation; such is the case in the epileptic deliria and acute confusional insanity. Distinctness of perception is therefore a condition necessary for the normal functioning of memory; it is, however, not in itself a sufficient condition. An impression, though very clear and very precise at the moment, may not fix itself upon the mind. Thus in the polyneuritic psychosis the patient understands per- fectly the questions put to him, executes properly the orders that are given him, so that on a superficial 60 MANUAL OF PSYCHIATRY. examination he may convey the impression of a normal individual; still he preserves but an incomplete recollec- tion, or none at all, of the occurrences of the whole period of his illness. It seems, then, that for proper fixation is required, besides sufficient distinctness of perception, some other condition the nature of which is as yet undetermined. B. Retrograde amnesia by default of conservation. — An impression fixed in the memory is preserved for a greater or lesser length of time, depending upon its nature and upon the individual capabilities of the subject. The memory of an important event persists longer than that of an insignificant one. Certain indi- viduals possess a prodigious memory, others a very poor one or almost none at all; between these two extremes there are infinite gradations. The disappearance, under the influence of some pathological, cause, of impressions previously acquired, constitutes what we have termed amnesia of conserva- tion. This destructive, and consequently incurable, form of amnesia is the principal factor of dementia, and is often the first sign that warns the patient's friends and relatives of the approaching condition. The disappearance of impressions may be more or less complete, depending upon the nature of the dement- ing process. While many precocious dements for a long tune preserve a relatively good memory, general paretics and senile dements present from the beginning of their illness a very marked amnesia, Amnesia of conservation is generally associated with the other two forms of amnesia: amnesia of fixation and amnesia of reproduction. SYMPTOMATOLOGY. 61 C. Retrograde amnesia by default of reproduction. — In the normal state, an impression fixed and preserved in the memory possesses the property of being revived under certain conditions. In pathological conditions this power of reproduction may be suspended: the impressions exist, but they are dormant and cannot be revived. This form of amnesia is encountered in many acute psychoses, notably in manic depressive insanity, in acute confusional insanity, and in the toxic psychoses. Its prognosis is of course much more favorable than is that of the preceding form. The course of amnesia. — The onset may be sudden or insidious; it is often sudden in amnesia of reproduction, — pure or associated with amnesia of fixation, — and almost always insidious in amnesia of conservation. Amnesia may be stationary, retrogressive, or pro- gressive; it is stationary when, certain impressions having become destroyed, the defect persists without increasing; retrogressive when the impressions, simply dormant, reappear little by little; and progressive when, as the pathological process continues to act, the number of destroyed impressions becomes greater from day to day. In progressive amnesia the disappearance of impres- sions occurs not at random, but in a definite order. " The progressive destruction of memory follows a logical course, a law. It descends progressively from the unstable to the stable: it begins with recent impressions which, fixed imperfectly upon the nervous elements, seldom repeated and therefore but feebly associated with others, represent the organization in its weakest degree; it ends with that instinctive ; sensory memory which ; stably fixed in the 62 MANUAL OF PSYCHIATRY. organism and having become almost an integral part of it, represents the organization in its strongest degree. From the beginning to the end the course of amnesia, governed by the nature of things, follows the line of least resistance, that is to say, the line of least organ- ization. " 1 In senile dementia, in which the law of amnesia is most perfectly demonstrated, the impres- sions of old age are the first to become effaced, later those of adult life, and finally those of youth and childhood. Some of the latter may remain intact long after the general ruin of the memory and of the other intellectual faculties. It is not uncommon to meet with advanced senile dements who, though incapable of recollecting the existence of their wife and children, are still able to relate with minute details the occurrences of their childhood or to recite correctly fragments from the works of classic authors. The law of amnesia, though always the same, is most difficult to demonstrate in those affections in which the enfeeblement of memory progresses very rapidly, where many impressions, like other manifes- tations of intellectual life, disappear en masse. In general paresis the course of the amnesia is much more rapid and much less regular than in senile dementia. This fact, as we shall see, is an important element in diagnosis. Varieties of amnesia. — Amnesia is said to be partial when it involves only one class of impressions, for instance proper names, numbers, certain special branches of knowledge (music, mathematics), or a 1 Ribot, The Diseases of Memory. SYMPTOMATOLOGY. 63 foreign language. A young man coming out of a severe attack of typhoid fever forgot completely the English language, which he had spoken fluently before the onset of the illness. Other impressions were quite well preserved. When it involves verbal images the amnesia determines a particular form of aphasia, amnesic aphasia. Amnesia is general when it affects equally all classes of impressions. Most of the progressive amnesias are general. Amnesia may be limited to a certain period of exist- ence. In such cases its onset is almost always sudden, and it is either anterograde, or retrograde by default of reproduction. Localization of recollections. — A recollection of an occurrence, once evoked, is usually easily localized by us as to its position in the past. This power of locali- zation disappears in certain psychoses. The patients cannot tell on what elate or even in what year some fact occurred, the impression of which they have, how- ever, preserved. The default of localization in the past combined with a certain degree of anterograde and retrograde amnesia produces disorientation of time. Illusions and hallucinations of memory. — In an illu- sion of memory a past event presents itself to the consciousness altered in its details and in its relation to the patient, and exaggerated or diminished in im- portance. Thus one senile clement claimed to have superintended the construction of a Gothic cathedral several centuries old, holding, as he said, "the calipers in one hand and the musket in the other to defend myself against the Saracens." Upon inquiry it was 64 MANUAL OF PSYCHIATRY. found that the patient had really worked about thirty years previously at the restoration of an old cathedral. The illusion of memory becomes a true hallucination when the representation perceived as a recollection does not correspond to any actual past occurrence. A patient who had been in bed during several weeks related once that on the previous day he assisted at the coronation of the Russian emperor: this is a repre- sentation without an object, an hallucination of memory. Illusions and hallucinations of memory form the basis of imaginary reminiscences 1 which are met with in many psychoses, especially in hysteria and in the polyneuritic psychosis. I shall mention lastly a curious form of illusion of memory, which has been designated by the name of " illusion of having previously seen. ... It consists in a be-ief that what is really a new impression for the patient was previously experienced by him, so that, though it is produced for the first time, it appears to him to be a repetition. ;; 2 One patient claimed that all the occurrences which he was witnessing had taken place a year previously, day by day. He made a great deal of noise at the marriage of one of his sisters, demanding to know why a ceremony which had already been performed a year ago was begun over again, and protesting that it was like a farce. 3 1 Delbriick. Die pathologische Luge und die psychisch abnormen Schwindler. — Koeppen. Ueber die pathologische Luge (Pseudologia phantastica). Charite Annal , Jan. 1898. 2 Ribot. Loc, cit. 3 Arnaud. Un cas d 'illusion du dejli vu ou de jausse memoire. Ann. mod. p.sych., May-June, 1890. SYMPTOMATOLOGY. 65 § 3. Associations of Ideas and Attention. Associations of ideas may occur as the result either of voluntary ideation or of the activity of the mental automatism. Voluntary associations of ideas. Attention. — The functions of attention are: 1) to govern the associa- tions; 2) to regulate the course of representations, that is to say to retain each of them for a greater or lesser length of time in the field of consciousness; and 3) to inhibit the automatic associations which may cause a deviation of the course of voluntary associations. Enfeeblement of attention is closely connected with a sluggishness of the voluntary associations of ideas. This latter symptom is manifested clinically by slowness of apprehension, and experimentally by an increase of the reaction-time, that is to say the time required for a sensation to be transformed into a voluntary and conscious movement. 1 Enfeeblement of attention and sluggishness of volun- tary associations constitute the earliest and most con- stant manifestations of psychic paralysis. Their intensity may be of three different degrees: 1st degree: diminished capacity for intellectual exertion, rapid fatigue; 2d degree: intellectual dullness; 3d degree: complete suspension of all voluntary intellectual activity. Enfeeblement of attention and sluggishness of asso- 1 Pierre Janet. Nevroses et idles fixes, Paris, F. Alcan. — Sommer. Lehrbuch der psychopalhologischen Untersuchungsmethoden, 1899. 66 MANUAL OF PSYCHIATRY. ciations may exist alone, as in certain forms of melan- cholia, and especially in stupor, in which they attain their highest degree. They may also be associated with an exaggerated activity of the mental automatism, which manifests itself by an abnormal mobility of attention and by a flow of incongruous ideas (flight of ideas, incoherence), or, on the contrary, by the ap- pearance in the field of consciousness of some particu- larly tenacious and exclusive representation (impera- tive ideas, fixed ideas, autochthonous ideas). Abnormal mobility of attention. 1 — In this condition any external impression, whatever it may be, suffices to capture the patient's attention, but nothing can fix it. This symptom exists in its purest form in mania. Flight of ideas. — Incoherence. — These two symptoms constitute two different degrees of the same morbid process. Flight of ideas, almost always dependent upon an abnormal mobility of attention, is constituted by a rapid succession of representations which appear in the field of consciousness without any order, at the, occasion of ex- ternal impressions, superficial resemblances, coexistences in time or space, similarities of sounds, etc. One word arouses the idea of another one of a similar sound or having the same termination (association by assonance). The following example from the case of a maniac, whose discourse during several minutes was copied verbatim, will show, better than a description could, the character of this pathological phenomenon: 1 It results from an exaggerated activity of what has been termed spontaneous attention in contradistinction to voluntary attention. SYMPTOMATOLOGY. 67 " Now I want to be a nice, accommodating patient; anything from sewing on a button, mending a net, or scrubbing the floor, or making a bed. I am a jack-of-all- trades and master of none! (Laughs; notices nurse.) But I don ; t like women to wait on me when I am in bed; I am modest; this all goes because I want to get married again. Oh, I am quite a talker; I work for a New York talking-machine company. You are a physician, but I don't think you are much of a lawyer, are you? I demand that you send for a lawyer! I want him to take evidence. By God in Heaven, my Saviour, I will make somebody sweat! I worked by the sweat of my brow! (Notices money on the table.) A quarter; twenty-five cents. In God we trust; United States of America; Army and Navy forever! " Flight of ideas was formerly considered, especially in mania, the result of excessive activity of the normal intellectual function; it was believed that the. patient, unable to express in words the ideas which crowd themselves into the consciousness, is compelled to leave out a large number of them, and that these omis- sions cause the disconnectedness of his discourse. In reality this exaggerated activity affects only the automatic intellectual functions and is always associated with an enfeeblement of the higher psychic functions. The essential cause of the phenomenon is to be looked for in a weakness of attention: representation A can- not fix itself upon the consciousness and is immedi- ately replaced by representation B, so that the ideas fly- While in flight of ideas the representations are still associated by their relations, which though superficial 68 MANUAL OF PSYCHIATRY. are yet real, in incoherence they follow each other without any even apparent connection. The following is a specimen of incoherent speech obtained from a case of dementia prsecox: "What liver and bacon is I don't know. You are a spare; the spare; that's all. It is Aunt Mary. Is it Aunt Mary? Would you look at the thing? What would you think? Cold cream. That's all. Well, I thought a comecliata. Don't worry about a comediata. You write. He is writing. Shouldn't write. That's all. I'll bet you have a lump on your back. That's all. I looked out the window and I didn't know what underground announcements are. My husband had to take dogs for a fit of sickness. " These few lines suffice to show the profound degree of psychic disaggregation which is manifested by this phenomenon. It is not infrequent to see the two symptoms, flight of ideas and incoherence, appear in succession, or even together in the same subject, notably in cases of mania and of acute mental confusion. Imperative ideas. — Fixed ideas. — Autochthonous ideas. 1 — We have stated above that mental automatism may manifest itself by the appearance of an idea that is particularly tenacious and exclusive, occupying by itself the field of consciousness from which nothing can dislodge it. 2 The three forms under which this phenomenon may present itself have been well defined by Wernicke. 3 1 Keraval. L'idee fixe. Arch, de Neurol., 1899, Nos. 43 and 44. 2 This form of mental automatism may be termed monoideal automatism. 3 hoc. ct., p. 108. SYMPTOMATOLOGY. 69 An imperative idea imposes itself upon the patient's consciousness against his own will; he recognizes its pathological character and seeks to rid himself of it. It is a parasitic idea, recognized by the patient as such. A mother is haunted by the idea of killing her child whom she loves dearly. As she herself states, she can no longer think of anything else; but she recognizes it as a morbid phenomenon and begs to be relieved of it: this is an imperative idea. A fixed idea, on the contrary, harmonizes with the other representations. Therefore it is never con- sidered by the subject as foreign to the mind or as a pathological phenomenon. A mother who has lost her child is convinced that if she had given it a certain kind of medicine the child would not have died. This idea does not leave her, appears to her perfectly legitimate and natural : this is a fixed idea. Fixed ideas form the basis of certain delusional states, notably that of paranoia. They are also the starting point of a great many hysterical episodes. In such cases they are often subconscious, that is to say, they exercise their influence without the patient's being conscious of their existence. Fixed ideas are not found exclusively in cases of mental alienation; they are encountered in the normal state as certain tendencies that may be in themselves perfectly legitimate. Such are the desires for ven- geance, ambition, etc. Autochthonous ideas, like imperative ideas, are de- veloped alongside of normal associations. The only difference is in the patient's interpretation of them; 70 MANUAL OF PSYCHIATRY. while the imperative idea is recognized by him as pathological, the autochthonous idea is attributed to some malevolent influence, most frequently to some strange personality. If he complains, it is to the police officer and not to the physician. A mother believes that her neighbor forces upon her the idea of killing her child: this is an autochthonous idea. Closely related to imperative ideas, autochthonous ideas present a similar analogy to hallucinations; like hallucinations, they result from the automatic activity of a cortical center. But, instead of playing upon a psychosensory center, the morbid irritation occurs in a psychic center. Baillarger designated autochthonous ideas by the term of psychic hallucinations. 1 This term has lately fallen into disuse, perhaps undeservedly. Nothing proves more conclusively the kinship of the two classes of symptoms than the frequent transforma- tion of autochthonous ideas into auditory, motor, and occasionally even visual, verbal hallucinations. The analogy between autochthonous ideas and verbal motor hallucinations led Seglas 2 to consider the two phenomena as identical in their nature, the first being but a rudi- mentary form of the second. This opinion will appear somewhat exclusive if we take into consideration the fact that autochthonous ideas may engender auditory hallucinations 3 just as readily as motor hallucinations, and that in many cases they are not accompanied by even the slightest sensation of movement. 1 Marandon de Montyel. Des hallucinations psychiques. Gaz. hebd. de Med. et de Chirurgie, March, 1900. 2 Lecons cliniques sur les maladies mentales et nerveuses. 3 Wernicke. Luc. cit. SYMPTOMATOLOGY. 7 1 Psychic hallucinations generally indicate; an advanced disaggregation of the personality and therefore point to a grave prognosis. § 4. Disorders of Judgment. Judgment is the act by which the mind determines the relationship between two or more representations. When the relationship is imaginary the judgment arrives at a false conclusion. This becomes a delusion when it is in conflict with evidence. False ideas which patients often entertain concern- ing their own condition, believing their health to be perfect when in reality it is seriously affected, are to be attributed to impaired judgment [lack of insight]. This lack of appreciation of their own condition is not always absolute, and though in general it may be truly said that insanity is a disease which does not recog- nize itself, it must, however, be acknowledged that sometimes, chiefly at the onset of the psychoses, the patients are conscious of pathological changes occurring in themselves. 1 Some spontaneously apply to the physician or even request to be committed. A sufferer from recurrent insanity, treated several times at the Clermont Asylum, had at the beginning of his attacks such a perfect realization of his state that he would request by tele- gram to have attendants sent after him. General features of delusions. — The ensemble of a patient's delusions constitute a delirium. 1 Pick. Ueber Krankheitsbewusstsein in psychischen Krankheiten. Arch f. Psychiat., Vol. XIII. — Heilbronner. Ueber Krankheitsein- sicht Allg. Zeitsch. f. Psychiat., Vol. LIV. No. 4. 72 MANUAL OF PSYCHIATRY. A delirium may consist of purely imaginary ideas, or it may be based upon actual facts improperly inter- preted. In the latter case we have delusional interpretations. When the delusional interpretations involve occurrences of the past the delirium is said to be retrospective. Sometimes the delirium follows a dream, is con- founded with it, and presents all the characteristics of it (dream delirium); such is the case in many infec- tious and toxic psychoses. Almost always the delusions are multiple. Even in those cases which are sometimes designated by the term monomania, the primary morbid idea entails a certain number of secondary morbid ideas which result from it. In some cases different delusional conceptions coexist without there being any connec- tion between them, in others they are grouped so as to form a more or less logical whole possessing greater or lesser probability. In the first instance the delirium is said to be incoherent, in the second systematized. Whether systematized or not, delusions, like hallu- cinations, generally harmonize with the emotional tone. This harmony disappears when the pathological process becomes abated in intensity, as the patient either enters upon his convalescence or lapses into intellectual enfeeblement. In dements the delusions often affect neither the emotions nor the reactions. A patient may claim that he is an emperor and at the same time agree to sweep the hall; another may believe himself to have lost his stomach and still eat with a hearty appetite. Three great categories of delusions are usually dis- tinguished : SYMPTOMATOLOGY. 73 Melancholy ideas; Ideas of persecution; Ideas of grandeur. We shall limit ourselves here to a rapid review of these, reserving the details to be considered in connec- tion with the affections in which the delusions occur. Melancholy Ideas. — Very frequent at the beginning of psychoses, melancholy ideas may persist through the entire duration of the disease, as in affective melan- cholia. The principal varieties are: (A) Ideas of humility and of culpability. The atter are also called ideas of self- accusation; (B) Ideas of ruin; (C) Hypochondriacal ideas; (D) Ideas of negation. A. Ideas of humility and of culpability. — The patient considers himself as a being good for nothing, wretched, undeserving of the attention bestowed upon him, and accuses himself of imaginary faults or crimes. Often he will seek out from his past life some insignificant act to which he will attribute extreme gravity: he stole some apples when he was a boy, or he forgot to make the sign of the cross once upon entering a church. The idea of the crime committed entails also ideas of merited punishment: he expects every instant to be arrested, put to death, cut to pieces, thrown into hell, etc. B. Ideas of ruin. — These are frequent in senile dements; the patient believes himself to be without any means, bereft of everything; his clothes will be sold; some day he will be found dead of starvation on some public road. 74 MANUAL OF PSYCHIATRY. C. Hypochondriacal ideas. — These concern the sub- ject himself, involving either the physical sphere — the stomach is obstructed, the spinal marrow is softened, the entire organism is affected by an incurable disease — or the psychic sphere constituting moral hypochon- driasis: the mind is paralyzed, the intelligence is destroyed, the will power is annihilated. D. Ideas of negation. 1 — In some cases these concern the subject himself, and are then nothing but hypochon- driacal ideas pushed to an extreme: the brain, the heart, etc., are destroyed, the bones are replaced by air, the body is nothing but a shadow without a real existence. In other cases they are referred to the external world: the sun is dead, the earth is nothing but a shadow, the universe itself exists no more (meta- physical ideas of negation). By a singular process, apparently paradoxical, hypo- chondriacal ideas and those of negation give rise to ideas of immortality and of immensity. The patient feeling himself, on account of the destruction of his organs, placed beyond the laws of nature, concludes that he cannot die, and that he is condemned to suffer eternally; or, dismayed by the form and monstrous dimensions of his body, he imagines himself obscuring the atmos- phere, filling the world, etc. Bv the name "the svndrome of Cotard" has been 1 Seglas. Lemons cliniqnes, p. 276. — Cotard. Du dclire des negations. Arch, de neurol., 1882. — Arnaud. Snr le dclire des negations. Ann. med. psychol., Nov.-Dec. 1892. — Seglas. Le dclire des negations. Encycl. des Aide-mem. — Trenel. Notes sur les idees de negation. Arch, de neurol., March 1899. — Castin. Un ras de dclire hypochondria que a forme evolutive. Ann. m£d. psych., June 1900. SYMPTOMATOLOGY. 75 designated a group of symptoms which is encountered in certain cases of chronic melancholic delusional states the constituent elements of which are: Ideas of negation; Ideas of immortality associated with ideas of damna- tion or of being possessed; ideas of immensity; Melancholic anxiety; Tendency to suicide; Analgesia. The general features of melancholic deliria are the expression of psychic inhibition and of the painful emotional state which constitute the basis of the melan- cholic state. The following is a summary of the chief character- istics of these states, according to the admirable study of Seglas : a) The melancholic delirium is monotonous; the same delusions are constantly repeated, the inhibition allowing but little formation and appearance of new ideas. b) It is an humble and passive delirium. The pa- tient accuses no one but himself, and submits without resistance to the ill-treatment which he believes him- self to be deserving of. c) As to localization in time, the delusions are referred to the past and to the future: the patient finds in the past the imaginary sins which he has com- mitted, and foresees in the future the chastisements which are to be inflicted upon him. The persecuted patient, on the contrary, localizes his delusions chiefly in the present. The persecutions of which he com- plains are- actual, 76 MANUAL OF PSYCHIATRY. d) From the standpoint of its development the melancholic delirium is centrifugal. The trouble begins with the subject himself and extends gradually to his friends, to his country, and to the entire universe, who suffer through his faults. e) The melancholic delirium is secondary, that is to say, it is the consequence of the sadness and of the moral pain. It shares this characteristic with most of the other delusional states which are generally but the expression of the emotional tone of the subject. 1 Melancholic delirium may have two grave conse- quences which I shall have a great deal of occasion to emphasize: suicide and refusal of food. Ideas of persecution. — Like melancholy ideas, ideas of persecution are of a painful character. But while the melancholiac considers himself a culpable victim and submits beforehand to the chastisements which he believes he has merited, the subject of persecution is convinced of his innocence and protests and defends himself. . Ideas of persecution may be divided into two groups, according to whether they are or are not accompanied by hallucinations. In the first group they are associated with halluci- nations, generally of an unpleasant character, among which auditory verbal hallucinations and hallucinations of general sensibility are most prominent. After a certain time the phenomena of psychic disaggregation supervene: motor hallucinations, autochthonous ideas, reduplication of the personality, etc. 1 S6glas. Logons cliniques. SYMPTOMATOLOGY. 77 In the second group the ideas of persecution are peculiarly associated with faulty interpretations; any chance occurrence is ascribed by the patient to malevo- lence; he sees in everything evidences of hostility against him, and attributes to the most ordinary and unimportant facts and actions a significance which is as grave as it is fanciful. This form of ideas of perse- cution is frequent at the onset of certain psychoses; it also constitutes the basis of an affection known as paranoia or reasoning insanity. Some patients do not know their persecutors. Others accuse some particular persons or societies (Jesuits, Freemasons). Still others bear their hatred towards some certain individual who is, in their eyes, the instiga- tor of all the injurious procedures of which they are the victims, "the great master of the persecutions/' as one such patient once said. Of all delusions those of persecution are the most irreducible and are entertained by the patients with the most absolute conviction. Almost always the patients resent to have them disputed. In themselves these delusions do not have an invariable influence upon the prognosis, excepting that, in a very general way, they are of more serious import than melancholy ideas. Of all delusions these also present the greatest tendency to systematization and to progressive evolution. A per- fectly systematized persecutory delirium should comprize : (a) A precise idea of the nature of the persecutions; (b) An exact knowledge of the persecutors, of their aim, and of the means employed by them; (c) A plan of defense in harmony with the nature of the delusions. 78 MANUAL OF PSYCHIATRY. In the examination of cases of persecutory delirium one should always attempt to determine these points, on account of their great practical importance. Ideas of grandeur. — Ideas of grandeur chiefly appear in demented states and are often of a particularly absurd nature, bearing the stamp of intellectual en- feeblement. The patients are immensely rich, all- powerful; they are popes, emperors, creators of the universe. Generally they naively declare these pom- pous titles without being at all concerned by the fla- grant contradiction existing between their actual state and their ostensible almightiness. A general paretic was once asked: "If you are God, how, then, does it happen that you are locked up?' 7 " Because the doctor refuses to let me go/' he replied simply. It is not rare to see a pseudo-pope obey without a murmur the orders of hospital attendants and assist with the best possible grace in the most menial labor. Often the patient's costume is in harmony with the title: uniforms of the oddest fancy, multicolored tin- sels, numerous decorations, etc. When the ' intellectual enfeeblement is less pro- nounced, as, for instance, in certain cases of dementia precox, the subject shows more logic in his conduct. He assumes an air of dignity, avoids all association with the other patients, and declines with a contemptu- ous smile all suggestions of employment. Ideas of grandeur are also met with in certain acute psychoses, as in mania, for instance, and in certain forms of systematized deliria without intellectual enfeeblement (" Paranoia originaire" of Sander). CHAPTER IV. SYMPTOMATOLOGY (Continued). AFFECTIVITY —REACTIONS.— CCENESTHESI A— NOTION OF PERSONALITY. § 1. Disorders of Affectivity. Pathological modifications of affectivity are en- countered in the course of all psychoses. They always appear early, and often before any of the other symp- toms. The principal ones are: (a) Diminution of affectivity: morbid indifference; (6) Exaggeration of affectivity; (c) Morbid depression; (d) Morbid anger; (e) Morbid joy. Diminution of affectivity. — In its most pronounced degree indifference involves all the emotions, as in extreme states of dementia (general paresis and senile dementia in their terminal stages), in which it is associa- ted with general intellectual enfeeblement. In its less severe forms the indifference is manifested by disap- pearance of the most elevated and the most complex sentiments, with conservation and often even exalta- 79 80 MANUAL OF PSYCHIATRY. tion of the sentiments of an inferior order. The altru- istic tendencies are the first to become effaced, while the egoistic sentiments persist. Only the satisfaction of their material wants still concerns the patients and governs their activity. Many take no interest during the visits of relatives in anything excepting the eatables brought to them; they eat as much as they can, fill their pockets with the rest, and leave without taking the trouble to express their thanks or even to bid their visitors good-by. The morbid indifference may be conscious or uncon- scious. In the first case it is realized by the subject as a painful phenomenon. The patients often say: "I have lost all feeling, nothing excites me, nothing pleases me, nothing makes me sad." Some complain of being unable to suffer. This state, which may be called painful psychic anaesthesia, is frequent at the beginning of psychoses and sometimes persists through the entire duration of the affection (affective melancholia, de- pressed periods of recurrent insanity). In the second case, which is more frequent, the dimi- nution of affectivity is not noticed by the patient. Such is always the case in states of dementia. The alteration of the other mental faculties, such as memory and general intelligence, are not necessarily proportionate to those of the affectivity. Notably, in dementia praecox it is not rare to find a fairly good memory and a relatively lucid intelligence coexisting with complete indifference. Exaggeration of affectivity. — Often combined with indifference, as has been shown above, exaggeration of affectivity is encountered in most mental affections, SYMPTOMATOLOGY. 81 congenital and acquired. It constitutes the basis of irritable and changeable moods and of the extreme irascibility so often seen among the insane and among degenerates in general. In the acquired psychoses it is an early symptom, appearing at times long before the other phenomena. An individual previously calm, gentle, kind, becomes disagreeable, ill-natured, violent. "He is completely changed/' is often remarked by the relatives. Irritability is almost always associated with vari- ability of moods. Disorders of affectivity serve to characterize a large and important group of patients included under the somewhat vague designation of " constitutional psy- chopaths." In these individuals the emotions are entirely out of proportion with their causes. The death of an animal plunges them into unlimited despair, the sight of blood brings on syncope, the most simple affairs preoccupy their minds so as to make them lose their sleep. Sensitive in the highest degree, they see in everything malevolent intentions, disguised reproaches. But their sentiments, though very intense, are of short duration; sorrows, enthusiasms, resent- ments are with them but a short blaze. Morbid depression. — Depression presents itself in pathological states, as it does in the normal state under two forms: active and passive. This distinction is founded upon the presence or absence, or rather upon the intensity, of the moral pain. While in active de- pression the moral pain is very prominent, in passive depression it is dull, vague, scarcely appreciable. In- deed, as Dumas says, ' c the element of pain is not absent 82 MANUAL OF PSYCHIATRY. in passive melancholia; but it is not an acute and dis- tinct moral pain. It is but vaguely perceived." 1 Passive depression. — The fundamental features of pas- sive depression are lassitude, discouragement, resigna- tion. It is always associated with a marked degree of psychic inhibition, aboulia, and moral anaesthesia, and may be complicated by delusions and hallucinations. It is accompanied by organic changes which have been extensively studied by physiologists (Darwin, Claude Bernard, Lange), and to which Dumas has de- voted one of the most interesting chapters in his book, "La tristesse et la joie." Depression is always associated with a state of per- ipheral and probably cerebral vaso-constriction, in which Lange believed he had found the immediate cause of this emotion. This vaso-constriction is very evident in the pallor of the skin, coldness of the extremities, and ab- sence of the peripheral pulse, which are constant fea- tures of the depression of melancholia.- The opinion of Lange is, however, too exclusive. "This vaso-con- striction, which in the peripheral organs results in coldness and pallor of the tissues, brings about in the brain a condition of anaemia, undoubtedly contributing to the maintenance of the mental and motor inertia; but it cannot be asserted with certainty that it is the only cause of these phenomena. Morselli and Bordoni- Uffreduzzi have shown long since, in fact, that the phenomena of depressed intellectual activity may ap- pear before the cerebral circulatory changes; this leads to the conclusion that depression begins with being the 1 La tristesse et la joie, p. 29. Paris, F. Alcan. SYMPTOMATOLOGY. 83 cause of the circulatory changes before becoming sub- ject to their influence." x In the very rare cases in which, in spite of the periph- eral vaso-constriction, the cardiac impulse retains its force, the blood pressure, according to the laws formu- lated by Marey, rises; this condition constitutes the first type of depression, depression with hypertension. But almost always the heart participates in the gen- eral atony which the depression gives rise to, so that the blood pressure falls in spite of the peripheral vasocon- striction: this constitutes the second type of depres- sion, depression with hypotension (Dumas). The respiratory disorders are no less constant than the circulatory ones. The respirations are shallow, irregu- lar, interrupted by deep sighing. The quantity of car- bon dioxide excreted tends to diminish . The general nutrition is impaired; this results in loss of flesh, which is but slight if the depression lasts no longer than a few days, and which persists as long as the affective phenomenon itself. The weight does not return to the normal until the depression disappears, i.e., until the patient either recovers or becomes de- mented. The appetite is diminished the tongue is coated, the breath is offensive. The process of digestion is accom- panied by uneasiness and often by pain in the epigas- trium. Finally, there is almost always constipation. The sluggish metabolism shown by the diminished elimination of carbon dioxide is also apparent from the quantitative and qualitative changes in the urinary Furnas, hoc. cit., p. 239. b4 MANUAL OF PSYCHIATRY. excretion. The quantity of urine voided in twenty- four hours is diminished. The quantity of urea, as well as that of phosphoric acid, is also diminished (Observa- tions of Dumas and Serveaux). The toxicity of the urine in depression is undoubtedly of interest, but the results so far obtained are somewhat conflicting. According to some authors it is increased, according to others, diminished. This subject, still in a state of confusion, should be excluded from the domain of practical psychiatry. Active depression. — The special feature of active de- pression is the moral pain, which is distinct and suffi- ciently intense to render the subject subjectively con- scious of it. The appearance of this new phenomenon modifies to a certain extent the fundamental symptoms which have been described in connection with passive depression. Like physical pain, moral pain tends to limit the field of consciousness, to exclude other intellectual manifestations, and to become what Schiile has desig- nated by the term pain-idea. In certain cases the disturbance of consciousness which it causes results in marked disorientation and confusion. These phe- nomena, caused by the pain, become less marked as the pain becomes abated in intensity and disappear as the paroxysm passes off. When moral pain attains a certain intensity, it results in anxiety. This phenomenon consists chiefly hi a feeling of oppression or constriction, most frequently localized in the precordial region, occasionally in the epigastrium or in the throat, and more rarely in the head. This peculiar feeling is always accompanied by SYMPTOMATOLOGY. 85 certain somatic phenomena, the most important of which are pallor of the skin, sometimes actual cyano- sis, panting respiration, general tremor, irregular and accelerated pulse, and dilatation of the pupils, which is often very marked. Anxiety is frequently seen in depressed states. It also occurs in obsessions. It may appear without cause in certain psychopaths (the paroxysmal anxiety of Brissaud). From the standpoint of the reactions, moral pain, like physical pain, may manifest itself either by a sort of psychomotor paralysis, — so that the patient remains immovable, with a haggard expression, silenced, so to speak, by the anxiety, — or by various phenomena of agitation. In the latter case, the more frequent, the pain, an active phenomenon, brings about a reaction which to a certain extent overcomes the fundamental psychic in- hibition and manifests itself by two symptoms which are frequently seen together, motor activity and delusions. Acting as a stimulus, moral pain overcomes the motor inertia of melancholia and gives rise to melancholic agitation, which is characterized by movements that are, in the normal state, the expression of violent despair. The patient wrings his hands, strikes his head against the wall, etc. The agitation of anxiety is essentially an expression of opposition, of resistance. The reactions are either automatic or governed by the delusions: movements of flight, refusal of food, attempts at suicide, etc. Suicide is one of the most formidable consequences of moral pain. Though most melancholiacs have a desire 86 MANUAL OF PSYCHIATRY. to die, the aboulia which characterizes the state of depression very seldom permits them to carry out their desire. On recovering part of their energy they are apt to make suicidal attempts. Delusions are a frequent but not a constant manifesta- tion of moral pain. They are absent in certain melan- cholias in spite of the existence of even very painful depression. What is the mechanism of the production of delusions in melancholia? The most widely accepted opinion is that of Griesinger: l "The patient feels that he is a prey to sadness ; but he is usually not sad except under the influence of depressing causes; moreover, accord- ing to the general law of cause and effect, this sadness must have a ground, a cause, — and before he asks him- self this question, he already has an answer; all kinds of mournful thoughts occur to him as explanations, dark presentiments, apprehensions, over which he broods and ponders until some of these ideas become so dominating and so persistent as to fix themselves in his mind, at least for some time. For this reason these delusions have the character of attempts on the part of the patient to explain to himself his own state." Though of great interest, this ingenious theory is perhaps somewhat too exclusive. Kraepelin remarked, in fact, that the delusions occurring in states of de- pression do not always present the character of expla- nations sought by the patient. Many melancholiacs instead of accepting the delusions, on the contrary 1 Griesinger. Pathologie und Therapie der psychischen Krank- heiten. SYMPTOMATOLOGY. 87 reject them, at least in the beginning. Again, the appearance of a delusion does not bring with it the rela- tive calm which would be expected if it would really constitute the explanation sought by the patient. It seems, then, that this interpretation, ingenious though it is, is rather superficial. The view of Dumas appears to be nearer the truth. The moral pain provokes delusions because it acts as a stimulus, struggling against the lassitude, and finally conquering it. Thus there is no logical relationship between the moral pain and the delusions, but rather a dynamic one. Morbid anger. — Pain, associated with a representation of its cause, and sufficiently intense to overcome the psychic paralysis which is an essential accompaniment of depression, results in anger. The violent and disordered reactions displayed in anger have a purely automatic origin, and are often associated with a disturbance of consciousness and of perception which finds various expressions in popular language; a man who is a victim of violent anger is often said to be "beside himself/' he " forgets himself." Tike all emotions, anger is accompanied by somatic changes. The principal ones are: an increase of cardiac activity and an elevation of arterial tension*, peripheral vaso-dilatation, chiefly noticeable in the face which assumes a congested appearance; jerky and convulsive respiratory movements; an increase of most of the secretions: abundant salivation (foam- ing), more or less jaundice, diarrhoea, polyuria; some- times a suspension of the milk secretion; an arrest of the menstrual flow; more or less marked cutaneous ansethesia; general tremor. 88 MANUAL OF PSYCHIATRY. Anger may be met with in all the psychoses, except- ing perhaps affective melancholia. It sometimes reaches the intensity of furor, notably in idiots, epilep- tics, and other patients with profound disorders of consciousness. It is always associated with morbid irritability and impulsiveness, of which it is but an expression. Morbid joy or morbid euphoria. — This presents itself "in two forms: one, a calm joy, analogous to passive depression; the other, an active, exuberant joy, analo- gous to active depression. The first when of average intensity manifests itself by a state of satisfaction, a vague sense of well-being. It is encountered in general paresis and in certain forms of tuberculosis. The optimism and astonishing con- tentment of some consumptives who have reached the last stage of their illness are well-known phe- nomena. When calm euphoria reaches its highest development it becomes ecstasy, in which it is not accompanied by any motor reaction. Such is the case in certain forms of mystic deliria. Much more frequent than this calm and tranquil form of euphoria, the active form, noisy, accompanied by motor reactions, is a constant symptom of the so- called expansive forms of psychoses: general paresis with excitement, mania, certain toxic deliria. Unlike depression, euphoria permits of an easy asso- ciation of ideas and quick motor reactions. These two phenomena do not always indicate real psychic activity. In fact most frequently in pathologic euphoria the associations formed are aimless, independent of all SYMPTOMATOLOGY. 89 voluntary intellectual activity, and the motor reactions bear the stamp of impulsive acts originating automat- ically. When pushed to a certain degree, the apparent rapidity of the associations develops into flight of ideas mentioned previously. 1 The aspect of the patient in euphoria is the direct opposite of that in depression. The expression is bright, smiling, with the head raised and the body upright. The speech is very animated and accom- panied by numerous gestures. The concomitant physical phenomena are in general those of joy, that is to say, the reverse of those of depression. First come the cardio-vascular and respiratory phe- nomena: peripheral (and probably cerebral) vasodila- tation, acceleration of the pulse, increased force of the cardiac impulse, and an elevation or a lowering of the blood pressure, depending upon whether the increased heart action does or does not compensate for the peripheral vaso-dilatation. The respirations are accelerated, deep and regular; the elimination of carbon dioxide is increased. The general nutrition is active, as is seen from the patient's gain in flesh and from the increase of excrementitious products in the urine. These different phenomena, constant in normal joy and frequent in morbid euphoria, are however absent in some cases, when other factors are present which counterbalance the favorable influence of joy. Such is the case when there is intense motor agitation, which, 1 See pp. 66 and 67. 90 MANUAL OF PSYCHIATRY. in spite of the euphoria, causes a rapid loss of flesh. Such is the case also when the underlying condition is some severe bodily affection. The general paretic or the consumptive with euphoria is none the less cachectic, for in such cases a generally flourishing state of health is not possible. Certain anomalies are very difficult to explain. Some maniacs show, instead of an acceleration of the pulse characteristic of states of euphoria, a slowing which is at times quite marked. I have observed in a young maniacal girl with marked excitement less than forty- five pulsations per minute for several days. This phe- nomenon has, I think, not as yet been satisfactorily explained. § 2. Disorders of the Reactions. The different psychic operations which we have so far considered, — perception, associations of ideas, affec- tive phenomena, — find their outward expression in the reactions. Like associations of ideas, reactions may be of two kinds: voluntary and automatic. Between a voluntary act accomplished in full self- possession and a purely automatic act there are all intermediate gradations; we pass from the one to the other by a gradual insensible transition. The partici- pation of the conscious will diminishes as that of the automatism becomes more prominent, or inversely. We have seen that in normal ideation voluntary and conscious associations tend to inhibit the automatic associations. Similarly the conscious will tends to inhibit the automatic reactions. SYMPTOMATOLOGY. 91 We shall study: (1) dboulia, or paralysis of voluntary reactions; and (2) automatic reactions. Aboulia. — Complete paralysis of the will brings about, depending upon the character of the case, either stupor or absolute automatism. When less pronounced it is manifested clinically by a general sense of fatigue and discouragement, by slowness and unsteadiness of the movements, and by the painful effort that is necessary for the accomplishment of all spontaneous or com- manded acts. The voluntary apparatus then resembles a rusty mechanism which works only with difficulty. Like sluggishness of the associations of ideas, which is in most cases associated with it, aboulia is a mani- festation of psychic paralysis. Automatic reactions. — These may be paralyzed to the same degree as the voluntary reactions and give place to the absolute inertia of stupor; or, on the con- trary, they may become exalted by reason of the enfeeblement of the conscious will. We distinguish: (A) positive automatic reactions; and (B) negative automatic reactions. (A) Positive automatic reactions are expressed clinic- ally by two phenomena: suggestibility and impulsive- ness. By suggestibility is understood a state in which the reactions are compelled by external impressions. Its most perfect expression is catalepsy, in which the limbs assume and retain the attitudes in which they are placed by the examiner. This phenomenon has been termed waxy flexibility (flexibilitas cerea). Many patients appear to have lost all individual will and are reduced to pure automatons. Some repeat 92 MANUAL OF PSYCHIATRY. exactly the words (echolalia) or the gestures (echo- praxia) of the persons around them. Others exhibit no spontaneous activity, but are able to execute without hesitation any command. Such is the case with hyp- notized subjects, certain catatonics, etc. Sometimes it suffices to start them moving, when they will con- tinue and accomplish a series of acts to which they are accustomed. Suggestibility is the dominant note of the character of certain individuals, mostly credulous and weak-minded, whose thoughts are governed by external impressions, whose will is nil, and whq yield to the domination of the most diverse influences, good or bad. Many criminals belong to this class. Impulsive reactions or impulses are to be divided into three groups: (a) the passionate impulses; (b) the simple impulses; (c) the phenomena of stereotypy. (a) The passionate impulses always depend upon an abnormal irritability. They are determined by causes that are often insignificant and are accomplished independently of any mental reflection. They are met with in a great many patients: constitutional psychopaths, epileptics, maniacs, etc. A maniac feels his neighbor give him a slight push; he immediately strikes him without reflecting that the latter had no malevolent intention, that he was perhaps even uncon- scious of having touched him, etc. This is a passionate automatic reaction. (b) The simple impulses, purely automatic, appear without any emotional shock and without a shadow of provocation. One patient suddenly threw into the fire the gloves, hat, and handkerchief of her daughter SYMPTOMATOLOGY. 93 who came to visit her at a sanitarium. Afterwards during a moment of remission she remembered per- fectly the act and the circumstances under which it was accomplished, but was not able to furnish any explanation at all for it. The impulse may be conscious. A patient is sud- denly seized with a strong desire to steal some object from a show-window, the possession of which could be neither useful nor pleasant to him; he does not yield to this impulse, which he recognizes as pathological. This is a conscious impulse. This phenomenon is closely allied to imperative ideas, of which it is but an accentuation. (c) Stereotypy consists in a morbid tendency to retain the same attitudes, or to repeat the same words or the same movements. Hence the three kinds of stereotypy : Stereotypy of attitudes; Stereotypy of movements; Stereotypy of language: verbigeration. Certain patients remain for hours at a time in the most uncomfortable attitudes; others will walk a long distance, taking alternately three steps forward and two backward; still others will repeat indefinitely the same phrase or the same verse. (B) Negative automatism. — This forms the basis of negativism and consists in the annulment of a a t o1uq- tary normal reaction by a pathological antagonistic ten- dency. The patient is requested to give his hand; the volun- tary reaction, which tends to appear and which would result in the execution of the command, is arrested, sup- 94 MANUAL OF PSYCHIATRY. pressed by automatic antagonism. This disorder of the will has been designated by Kraepelin, who has made an admirable study of it, by the term "Sperrung, " a word which, literally translated into English, means blocking. A more significant term perhaps would be psychic interference. The two antagonistic tendencies neutralize each other like waves of opposite directions in physics. On a superficial examination negativism may resem- ble aboulia. These are, however, two very different phenomena. While the latter, purely passive, is the result of a persistent paralysis against which the patient struggles with more or less success, the former, an active phenomenon, depends not upon a parafysis but upon a perversion of the will. Negativism is often manifested only in certain kinds of reactions. One patient who walks about without any effort does not open his mouth. Another who makes his toilet, eats unassisted, and even works, remains in complete mutism, making no response in spite of all perseverance on the part of the questioner. In a more marked degree negative automatism results not only in the arrest of normal reactions, but also in the production of contrary reactions. Thus if one attempts to flex the patient's head he extends it, and vice versa. If he is reo^ested to open his half-shut eyes he closes them, and if the examiner attempts to force them open, his orbicularis muscle con- tracts in a veritable spasm. Wernicke observed that while flexibilitas cerea chiefly shows itself in the limbs, negativism mostly affects the muscle groups of the head and neck. SYMPTOMATOLOGY. 95 § 3. Disorders of Ccenesthesia and of the Personality. Disorders of coenesthesia. — By coenesthesia or vital sense is understood "the general feeling which results from the state of the entire organism, from the normal or abnormal progress of the vital functions, par- ticuarly of the vegetative functions " (Hoffding.) The stimuli which produce this sense are vague and poorly localized, and are perceived not individually but together as a whole. The harmony which normally exists between the di- verse organic functions produces a vague sense of satis- faction and of well-being. All causes tending to destroy this harmony will produce in the consciousness a feeling of malaise and of suffering more or less definite and more or less acute. Thus the disorders of coenesthesia are intimately connected with disorders of affectivity; most of the depressed states have for their basis an alteration of the vital sense. Disorders of the personality. — Alterations in the per- sonality constitute the symptom which, following Wer- nicke, we have termed autopsychic disorientation. These disorders may be arranged in three principal groups : (a) Weakening of the notion of personality; (b) Transformation of the personality; (c) Reduplication of the personality. (a) The notion of personality may be incomplete or absent; it may have never been developed at all, or it may have been but incompletely developed, as in idiots 96 MANUAL OF PSYCHIATRY. and imbeciles, or it may have disappeared or have be- come weakened under the influence of a pathogenic cause, as in mental confusion, epileptic delirium, melan- cholic depression with stupor, etc. (b) Transformation of the personality may be complete or incomplete. In the first case the patients forget or deny everything pertaining to their former personality. Thus one patient claimed that she was Mary Stuart, wanted to be ad- dressed as "Her Majesty the Queen of Scotland," and attired herself in costumes similar to those of that time. She became furious when called by her own name, and obstinately refused to accept the visits of her husband and children, whom she called " impostors. " Another patient, afflicted with hysteria, believed herself to have been transformed into a dog; she barked and walked on all fours. Still another patient at the Salpetriere re- ferred to herself as "the person of myself. " Complete transformation of the personality ma}^ be permanent, constituting, according to the excellent ex- pression of Ribot, a true alienation of the personality; or it may be transitory, so that the new ego disappears at a certain time to be replaced again by the former ego. In cases in which the normal personality and the pathological one replace each other mutually several times we have variation by alternation. 1 Incomplete transformation of the personality exists in a great many cases in which the patients are led by their delusions to attribute to themselves imaginary talents, powers, or titles, without at the same time completely 1 Ribot. TJw diseases of persoJiality. SYMPTOMATOLOGY. 97 abolishing their real ego. One patient suffering from chronic delirium of old standing claimed that he was St. Peter, and explained that he had been incarnated in an earthly man for the purpose of bringing happiness to mankind. A general paretic claimed that he was Emperor of Asia, reigning in Pekin, being at the same time aware of the fact that he was living in Paris, and was a newspaper vender. Gamier and Dupre have described under the name of paroxysmal mental puerilism 1 "a retrogression of the intellect to its primitive stages/ ; a state in which the subject once more becomes psychically a child, the transformation being only a temporary one. In the observation which they report a woman of thirty-three years took pleasure in childish amusements, such as play- ing with dolls, etc., and expressed herself in such childish language that she created the impression "not of an adult woman of thirty-three years, but of a child of .five years." This interesting syndrome is encountered in the most diverse affections. It may be met with in hysteria, in cerebral tumors, in abscess of the brain, etc. (c) Reduplication of the personality consists in the development of a new personality of a parasitic nature alongside of the real personality of the patient. This reduplication is the origin of the idea of posses- sion so frequent in the chronic melancholic deliria and results in a psychic disaggregation the most impor- tant manifestations of which are autochthonous ideas 1 Transformation de la personnalite. PiUrilisme mental paroxys- tique. Presse medicale, 1901, No. 101. 9 $ MANUAL OF PSYCHIATRY. (psychic hallucinations) and motor hallucinations. As I have had occasion to indicate above, the patient, feel- ing that he is losing control of his own thoughts and movements, concludes that a strange personality has taken possession of him. CHAPTER V. THE PRACTICE OF PSYCHIATRY. EXAMINATION OF PATIENTS. — GENERAL THERA- PEUTICS OF THE PSYCHOSES. § 1. Examination of Patients. The data for the diagnosis, prognosis, and treatment are obtained in psychiatry, as in all the other branches of medicine, from the anamnesis and from the direct examination of the patient. The anamnesis. — An anamnesis as complete as possi- ble is indispensable for an accurate diagnosis. It should be based upon information obtained from the patient's relatives, and from the patient himself when he is in a condition to give accurate answers concerning the family history and his personal history. A knowledge of the family history enables us to deter- mine the causes of inherited or simply congenital de- generation, to the influence of which the patient has been exposed. • A knowledge of the personal history, still more im- portant, informs the physician: (1) as to whether the disease is congenital or acquired; (2) in the case of acquired psychoses, (a) as to the nature of the soil (presence or absence of congenital psychic anomalies)- (b) as to the causes of the disease; (c) as to its mode t of onset and its duration. 99 100 MANUAL OF PSYCHIATRY. It is customary in many hospitals to obtain from the relatives or from the family physician replies to a definite series of questions on regular blanks. Not- withstanding the very considerable advantages of this method, it ought not to be used exclusively ; the alienist should not neglect in addition to interrogate personally all those who are in a position to furnish further infor- mation. Direct examination of the patient. 1 — Three classes of cases may be met with: (1) The patient himself, realizing his condition, applies to the physician; the examination is then conducted by a routine method. (2) The patient, not realizing his condition, but de- mented and indifferent, submits passively to the ex- amination. The task of the physician is rendered some- what more difficult on account of the lack of precision and veracity in the information furnished by the subject. In both these cases it is justifiable to proceed with a methodical examination conducted according to a plan previously laid out. (3) The patient does not realize his condition, but is lucid. Being convinced that he enjoys perfect mental soundness, he does not understand why the physician should pry into his personal affairs, and refuses to answer questions which to him seem useless or, worse still, inspired by ill-will; the physician's role is here very delicate. He must endeavor to obtain the confidence of the [ l The physical examination is, of course, of extreme importance. For the methods of physical examination the reader is referred to standard works on diagnosis, neurology, and practice of medicine.] THE PRACTICE OF PSYCHIATRY. 101 patient, and the best means of doing this is undoubtedly that recommended by Regis: he should introduce him- self, frankly as a physician called by another member of the family. In some rare cases he may be obliged to conceal the fact that he is a physician and to intro- duce himself as a fictitious person in some particular capacity which may suggest itself in the given case. In such cases the examination is often limited to a simple conversation directed so as to furnish the greatest possible amount of information concerning the patient's mental state. An important rule which should always be remembered is never to dispute the patient's delu- sions. It may be useful in the diagnosis to find out how the patient takes the disputing of his delusions; but all such attempts require extreme prudence, if one wishes to avoid irritatmg the patient and thus hindering the examination. Whichever procedure is adopted, methodical ques- tioning or conversation, the data gathered by the physician should permit of establishing: (1) The degree of intellectual development; (2) The state of the consciousness and orientation; (3) The degree of insight which the patient may have into his condition; (4) Delusions, if any, and their degree of systemati- zation; (5) The changes of the affectivity and the character of the patient's tendencies. Some commonly employed procedures often enable one to obtain these points of information very quickly. Such are questions concerning the patient's surround- ings, his age, his occupation, his family. 102 MANUAL OF PSYCHIATRY. The three questions, "How old are you?" "In what year were you born?" and "What year is this?" put to the patient successively inform us by the degree of accuracy of the replies obtained: (1) as to the patient's orientation of time; (2) as to the condition of his memory, — that of fixation as well as that of conservation and reproduction; (3) as to the condi- tion of the patient's judgment, by the presence or absence of flagrant contradictions in the replies: the patient may state, for instance, that he is fifty years old, was born in 1882, and that the present year is 1902. Tests of reading and writing are also very use- ful. The first consists in requesting the patient to read aloud some paragraph in a book or in a newspaper and several minutes later having him give an account of what he has read; this account is more or less accurate and complete. This test may demonstrate any exist- ing disorders of: (1) perception; (2) attention and asso- ciations of ideas; (3) the power of fixation; (4) the patient's speech (physical impediments). The second test, that of writing, consists in asking the patient to write something, either of his own pro- duction or from dictation or copy. This test furnishes information not only concerning the degree of general intelligence but also concerning some motor functions (tremulous or irregular handwriting), and often con- cerning the patient's delusions. Thus one patient, requested to write a letter to his family, began his letter with the following very sig- nificant words: "In the name of the Father, the Son, THE PRACTICE OF PSYCHIATRY. 103 and the Holy Ghost, We, the Emperor of Asia," etc. 1 Simulation and dissimulation. — The physician, * in considering the question of insanity, should not accept without verification the statements of the subject pre- sented to him for examination, for he may be a simulator or a dissimulator. It is often very difficult to discover simulation. Undoubtedly most individuals who practice it, being but little informed on insanity, do not represent the known types of psychoses: the attitudes, the gestures, the reactions, and the conversation present a constrained, affected aspect of voluntary exaggeration which at the very start may arouse the suspicions of the physician. Still the clinical types are as yet but poorly defined in psychiatry, and it would be extremely imprudent to declare the existence of simulation merely from an unusual combination and character of the symptoms. Affectation in action and in speech, extreme incoher- ence, apparently voluntary, are seen in catatonia; the agitation of certain hysterical patients, and even of some maniacs, often increases when the patients feel themselves being observed. The principal elements upon which the diagnosis of simulation is to be based are as follows: (a) The existence of a motive : legal prosecution, some sentence or punishment which the subject may seek to escape or military service which he may wish to evade; [ x The above are but the general directions for a hasty procedure leading merely to the determination of the absence or presence of mental derangement. For the methods of obtaining a complete mental status, see Sommer's Diagnostic der Geisteskrankheiten.] 104 MANUAL OF PSYCHIATRY. (b) The sudden appearance of the symptoms (agi- tation, delusions, confusion, stupor), without prodro- mata, which is very rare in the psychoses; (c) The constant observation of the subject whose conduct is often in discord with his delusions or with his simulated disorder of affectivity; a pseudo-melan- choliac, who declares himself the greatest criminal on earth, loudly demands to be put to death, and refuses food, will hide himself in a corner to devour with avidity a piece of bread stolen from another patient, and will sleep quietly when alone in his room believing himself to be unobserved. A similar contradiction is encoun- tered in certain established dementias, but never in the beginning of psychoses. However, the certainty of simulation, even when based upon the confession of the subject, does not necessarily indicate that the subject is a normal and fully responsible individual. The idea itself of simulat- ing a mental affection can arise only in an individual who is psychically abnormal. Joffroy quotes a remark of Lasegue: "One must be morbid to be a simulator of insanity." Dissimulation x is the opposite of simulation. Certain of the insane, almost always of the dangerous class, such as paranoiacs with ideas of vengeance or melan- choliacs with ideas of suicide, make efforts to conceal their morbid tendencies by assuming an outward appearance of calmness or even of happiness. They pretend never to have shown, or at least to have re- covered from, the mental disorders attributed to them; ■» . 1 Pasquet. Les alicncs dissimulateurs. These de Paris, 1898 THE PRACTICE OF PSYCHIATRY. 105 some admit having been ill, but affirm that it is all over and that they think no more of " their former follies. " These patients are sometimes spoken of as being reticent. Only the most intelligent and painstaking observation of all the details of the case will enable one to recognize dissimulation; the attitudes and gestures of the patient must be taken into account, his soliloquies or conver- sations with the " invisibles" to whom he abandons himself when he thinks he is alone, and finally his writings. The latter are of primary importance: many dissimulators who conceal their ideas in conver- sation do not hesitate to put them on paper in the form of memoranda or of letters to editors of periodicals or to government officials. § 2. General Therapeutic Indications : Sanitari- ums. — Commitment. — Treatment of Excitement, of Suicidal Tendencies, and of Refusal of Food. There is no particular treatment suitable for all mental diseases any more than there is for all affections of the stomach or of the kidneys. Certain therapeutic indications, however, are of such importance and frequency that it would be of use to make a general study of them. Some are relative to the surroundings in which the patients should be placed, others to certain particularly grave manifestations of mental diseases: excitement, suicidal ideas, and refusal of food. Surroundings: sanitarium commitment. — It is neces- sary in most of the psychoses to procure for the patient absolute physical and intellectual repose and to relieve 106 MANUAL OF PSYCHIATRY. him so far as possible from his preoccupations, delu- sional or rational. These indications are difficult to carry out in the ordinary conditions of life. The obstacles are of a nature both material and moral . material, because only few families can afford the expense involved in the treatment of an insane patient at home; and moral, because the relatives, inexperienced in the treatment of mental diseases, are not likely to carry out properly all the orders of the physician, and may cause an aggra- vation of the patient's condition by yielding to all his caprices, being under the impression that he must not be contradicted, and by wearying him in their attempts to reason with him or to distract him. The removal to a sanitarium is therefore in most cases inevitable. All insane patients may be grouped in two classes: the inoffensive and the dangerous. For the first class of cases the sanitarium does not present any particular features and the admission of the patient is effected with no more formality than that into a general hospital. The patients of the second class must be committed or isolated; this must be accomplished under the super- vision and responsibility of a public authority, and entails certain formalities. 1 ' Of all these formalities only one is of interest to us here: the physician's certificate of lunacy. [' The original text here contains an extensive quotation of the French insanity law; for obvious reasons it has been obmitted in the translation.] THE PRACTICE OF PSYCHIATRY. 107 The certificate, intended to establish the legitimacy of the commitment, need not contain any detailed observations and does not necessarily involve a precise clinical diagnosis. It is of little importance here whether the patient does or does not present inequality of the pupils or abolition of the patellar reflexes. It is also unimportant whether he suffers from mania or from dementia prsecox, as long as the symptoms which he presents render him a menace to himself, to others, or to the public peace. The indications for commitment are chiefly to be based on the dangerous tendencies of the patient: a senile dement who is quiet and tractable can without any inconvenience be cared for at home or in an asylum for old men; another who is on the contrary irritable and violent should be committed without hesitation. In a general way the following symptoms should be considered as indications for commitment: impulsive tendencies; suicidal ideas; ideas of persecution and hallucinations which bring about violent reactions; states of dementia associated with phenomena of excitement. The character and intensity of the symptoms should, however, not be the only factors governing the action of the physician. He should also take into account their probable duration. If the mental disorder is not likely to persist for more than several days and has no tendency to recur frequently, commitment is not justifiable; such is the case in febrile deliria. Transfer of the patient to the asylum. — Undoubtedly it is the physician's duty to induce the patient to go to a hospital. Unfortunately this is not always easy 108 MANUAL OF PSYCHIATRY. or even possible when the question is one of commitment. If the patient is lucid, as in cases of chronic delirium or paranoia, one is often compelled, in order to avoid painful scenes, to resort to certain subterfuges, such as proposing to conduct him to some place where he desires to go, or inviting him to go out on an excursion. This question, at times delicate, cannot of course have a universal solution. Medico-legal testimony. — The purpose of medico- legal testimony is to inform the public official, most frequently a judiciary authority, as to the mental state of the individual submitted to an examination by an expert, and particularly as to his responsibility. The word " responsibility " is used here not in a meta- physical sense, but in a practical one, and is to be defined as "the faculty of adapting (so far as possible) our mental life to the external world, and especially of adapting our mental life to that of other individuals." 1 According to this definition any individual should be declared irresponsible who presents psychic anoma- lies which prevent his " adapting himself to the external world and to life in society." Thus understood respon- sibility has an infinite number of degrees. In fact " between those who adapt themselves very well and those who cannot adapt themselves at all there are all those who can adapt themselves, but imperfectly, only to certain aspects of social life: persons having but a limited responsibility. Between these two ex- 1 Forel. Ueber die Zurechnungsfahigkeit des normalcn Menschen. Munich, L901. — Forel et Mahaim. Crime et anomalies mentales coiislUutionellc.'i, 1902, Paris, F. Alcan. THE PRACTICE OF PSYCHIATRY. 109 tremes are all the imaginary transitions that exist between perfect health and disease" (Mahaim). The medico-legal report comprises: (1) A study of the subject's personality and of the modifications which it has undergone, if any; (2) In criminal cases, a study of the offenses for which he is indicted, or upon which the parties con- cerned base their accusations against the subject or their demands to annul agreements or engagements that they may have made with him; (3) Where possible, a precise diagnosis and prognosis; (4) Finally, conclusions as to the degree of responsi- bility which may be attributed to the subject. The . information which should guide the expert in making out the report is derived from four principal sources : (1) The direct examination and (2) prolonged obser- vation of the subject. This, to be of real value, should be conducted in a hospital. Indeed a great many important peculiarities in the conduct and conversation of a subject submitted for an expert's examination remain unnoticed by persons inexperienced in insanity, — prison guards, for instance; (3) The expert's inquiries from persons who are in a position to furnish information concerning the patient ; (4) A judiciary inquiry the data of which the physician is a priori obliged to accept as true in the absence of other evidence. The importance of the judiciary inquiry is extreme and in many cases furnishes the essential element of diagnosis. For instance, in the case of a crime committed by a paranoiac whose entire derangement consists in a single false idea which 110 MANUAL OF PSYCHIATRY. does not always appear as an absurd idea on first con- sideration, only the judiciary inquiry can determine whether the allegations of the patient are true or not. TREATMENT OF EXCITEMENT. Perhaps the greatest progress in the therapeutics of mental diseases within the past few years has been made in our methods for the treatment of excitement. Little by little means of restraint, always useless, often barbarous, have disappeared from asylums. The honor of having introduced into France the "no restraint/ ' or treatment of excitement without mechanical restraint, belongs to Magnan (1867). The methods employed to-day in combating excite- ment may be grouped under four principal headings: Rest in bed; Hydrotherapy ; Isolation; Medication. Rest in bed. 1 — First used in melancholia (Guislain, Griesinger, Ball), rest in bed has been only since recently employed in the treatment of excitement. Magnan has introduced its use into France, after having shown the excellence of its effects and the relative facility of its employment. Rest in bed presents the triple advantage of saving the patient's energy, calming the excitement, and facilitat- ing supervision. It is indicated in most of the acute psychoses and in the periods of exacerbation of chronic 1 Pochon. These de Paris, 1899. — Wizel. Ann. med. psych., 1901. — Serieux et Farnaricr. Ann, mcd. psych., 1900. THE PRACTICE OF PSYCHIATRY. Ill psychoses. Rest in bed need not necessarily be con- stant to be efficacious, except in cases in which the gravity of the general condition requires it. It is well to allow patients to get up for two or three hours daily, using part of the time for outdoor walks the duration of which is to be determined by the special indications in each case. Rest in bed produces the best effects when carried out collectively in small dormitories containing not more than ten beds. The example of patients who have already submitted to this mode of treatment exercises a salutary influence upon the newcomers and helps to induce them also to accept it. Under favorable con- ditions two or three days generally suffice for even a very excited maniac to become accustomed to staying in bed, and to become calmed to a certain extent. Though he may still persist in restless movements, he rarely leaves his bed, and when he does, he will return without difficulty upon the simple injunction of the nurse. Hydrotherapy. — The cold douche, formerly much em- ployed for calming excitement, acts chiefly by its asphyxiating effect. It is therefore not surprising that it has been entirely abolished. Of the various forms of hydrotherapy two are most frequently used: the wet pack and the prolonged warm bath. - The wet pack is applied by means of a sheet soaked in cold water and closely wrapped around the entire body. Its duration varies from twenty minutes to several hours. If too prolonged it may cause attacks of syncope. Prolonged warm baths are of great service when rest 112 MANUAL OF PSYCHIATRY. in bed does not suffice to calm the patient. As gener- ally used their duration does not surpass five or six hours daily. Some physicians, however, have obtained good results from the permanent warm bath: the patient remains in the bath for days or weeks. 1 Most alienists have abandoned the old-fashioned cov- ered bath-tubs intended to imprison the patient. If necessary he is simply kept in by several nurses until the calming effect of the bath becomes apparent. Isolation. — Much combated of late, isolation presents, in fact, certain inconveniences, the gravest of which is leaving the patient by himself without constant super- vision; it is absolutely contraindicated in patients with suicidal tendencies, and should not, as a rule, be em- ployed until the other measures, — rest in bed and pro- longed baths, — have been tried. Nocturnal isolation consists in allowing the patient to sleep in a separate room which should, of course, be conveniently accessible to the attendant; it is of great utility in certain chronic disturbed patients. Many a dement who makes a great deal of noise during the night in the dormitory will repose quietly when he is alone. Medication. — I shall limit myself to the mention of those drugs which are most frequently used in states of excitement, and to giving several formulas. Opium in all its forms is used for the insane: extract of opium in pills, aqueous solutions for subcutaneous injections, tincture of opium, etc. The danger of forming the habit prevents the use of morphine in cases requiring prolonged treatment. 1 Sorieux. Le traitement des Mats d'agitation par le bain per- manent. Revue de Psychiatric, Feb., 1902. TEE PRACTICE OF PSYCHIATRY. 113 Chloral enjoys a merited reputation. It is adminis- tered in solution by the mouth in doses of from two to three grams for women and from three to four grams for men, or per rectum in doses of from four to five grams for women and from five to six grams for men. Chloral hydrate 2-4 grams Syrup of currant-berries 30 Water, enough to make 60 c.c. To be administered in one or two doses by the mouth. Chloral hydrate 5 grams Yolk of egg .• 1 Milk 120 grams To be administered per rectum, preceded by a simple enema. Chloral may be combined with bromides: Chloral hydrate 2 grams Potassium bromide 4 Syrup of currant-berries 30 " Water, enough to make 80 c.c. To be administered in one or two doses by the mouth. Chloral should be absolutely prohibited in cases of heart-disease. Bromides may also be used alone in doses of from two to eight grams. Sulphonal, trional, and tetronal bring about calm and prolonged sleep in cases of moderate excitement, given in doses of one, two, or three grams. They are usually administered in powders each containing one gram of any one of these hypnotics. One, two, or three such powders, according to the case, is to be administered 114 MANUAL OF PSYCHIATRY. in the evening towards six o'clock, the action of these drugs being slow. Chloralose, hypnal, and somnal may also be of service. Chloralose 20 to 60 centigrams. Given in a powder. Hypnal 2 grams Chloroform-water 100 " Syrup of peppermint : 30 " To be administered in two or three doses by the mouth. (Debove and Gourin.) Somnal 2 grams Syrup of currant-berries 40 " Water 20. " To be administered like the preceding. (Debove and Gourin.) Paraldehyde may be given by the mouth, by the rec- tum, or hypodermically in doses of from 2 to 5 grams. It is an excellent hypnotic. Its only inconvenience is the disagreeable and persistent odor which it imparts to the breath. Paraldehyde 2-5 grams Rum 20 " Lemon-juice 20 drops Simple syrup 30 grams Distilled water 40 ' ' To be administered in one or two doses by the mouth. (Debove and Gourin.) Paraldehyde 4 grams Yolk of egg 1 Milk. 120 grams THE PRACTICE OF PSYCHIATRY. 115 To be administered in one dose per rectum, preceded by a simple enema. Paraldehyde. . 5 grams Cherry laurel- water 5 l ' Boiled distilled water 15 " For hypodermic injection. Hyoscine [hydrobromate or] hydrochlorate is a very active drug and must be used with great caution. It may be administered in solution, in pills, or by subcutaneous injection. Hydrochlorate of hyoscine 0.005 gram Syrup of peppermint 30 grams Water enough to make 120 c.c. A tablespoonful every ten minutes until five doses have been given. Hyoscine hydrobromate . 02 gram Water 20 grams For subcutaneous injection. One ordinary hypodermic syringeful contains one mil- ligram of the drug. Half a syringeful is given at first; it is very rare that the sedative effect is not produced by a whole syringeful. SUICIDAL TENDENCIES. Suicide among the insane is perhaps the greatest source of anxiety to the practical alienist. 1 All the forms of mental alienation, excepting perhaps 1 Viallon. Suicide et folie. Ann. med. psych., 1901. 116 MANUAL OF PSYCHIATRY. mania, may give rise to ideas of suicide, but the first place from this standpoint belongs to psychoses of the depressed form (affective melancholia, depressed form of manic depressive insanity, certain forms of alcohol- ism, etc.). Whatever the nature of the disease may be, ideas of suicide may result : (a) From an imperative hallucination: a voice calls the patient to heaven, orders him to die in atonement for his sins, etc.; (b) From a delusion: fear of death from starvation, of being afflicted with an incurable disease; some pa- tients commit suicide to escape the imaginary persecu- tions of their enemies; (c) From an unconquerable disgust for existence (tedium vita?) or from an intolerable moral pain; (c?) From a sudden impulse (catatonia) ; (e) From a suggestion: family suicide, epidemics of suicide ; (/) From a fixed idea, the origin of which is inex- plicable. Such is the case reported by Ferrari: An officer declared on several occasions that it was ridicu- lous to live beyond sixty years. On the last day of his sixtieth year, after having passed a merry evening with his friends, he announced his intention of committing suicide. He went into his room and shot himself with a revolver. The smallest objects may become in the hands of patients deadly weapons which they may turn against themselves. Magnan reported a case of a melancholiac who perforated his heart by means of a needle measur- ing scarcely 3 centimeters in length. Some insane in- THE PRACTICE OF PSYCHIATRY. 117 dividuals at times resort to procedures so horrible that their use cannot be explained otherwise than by the existence of marked anesthesia; thus a patient of Baillarger's applied his forehead to a red-hot plate of iron. In asylums, where the patients are not allowed to have in their possession any dangerous instruments, the means most frequently made use of is hanging, which fact is explained by the extreme simplicity of the pro- cedure. Together with suicide may be classed the self-mutila- ations which patients frequently commit. Insane patients have been observed to cut off their own fingers, lacerate or even cut off their genital organs by means of pieces of glass, open their abdo- mens, etc. The treatment of suicidal tendencies is reduced to strict and constant watching, which should be insti- tuted as soon as the existence of such tendencies is suspected, and continued for a long" time after their apparent disappearance. As we have already stated above, isolation is absolutely contraindica'ted. Keep- ing the patient in the observation ward and rest in bed during the acute periods are very useful measures. REFUSAL OF FOOD (SITIOPHOBIA). Refusal of food * may result from: (a) Delusions with or without coexisting hallucina- 1 Pfister. Die Abstinenz der Geisteskranken und Hire Behandlung, Freiburg, 1899. 118 MANUAL OF PSYCHIATRY. tions: fear of being poisoned or of not being able to digest the food; hypochondriacal ideas; (6) The desire to starve to death; (c) An unconquerable disgust for food; (d) Negativism (catatonia, general paresis). Refusal of food may be partial or complete. Some patients will accept only certain kinds of food, often because these appear to them to be the safest or because "the voices" order them so. One patient lived solely on eggs, the shell seeming to him to be the only impene- trable barrier to the mysterious agencies used by his persecutors. It may be also absolute or relative. Often with a little perseverance one may persuade a melancholiac to accept a sufficient quantity of nourishment in a con- venient form. Some catatonics refuse what they have been offered and several minutes later devour their neighbor's meal without there being any delusion to explain their conduct. When the refusal of food threatens to have a bad effect upon the health of the patient, as is shown by loss of weight determined by systematic weighings, one must resort to forced feeding or " tube-feeding. ;; Tube-feeding may be accomplished in two ways: by the nose and by the mouth. Tube-feeding by the mouth is the less painful and less dangerous procedure for the patient as well as the most convenient one for the physician. The necessary mstruments are a mouth-gag, a stomach- tube, and a glass or rubber funnel. The operation itself is performed in four stages: (1) Opening the mouth; THE PRACTICE OF PSYCHIATRY. 119 (2) Introducing the tube into the stomach; (3) Attaching the funnel to the tube and tests for ascertaining the proper penetration of the tube into the stomach; (4) Introducing the liquid food. The first stage presents several difficulties due to the resistance of the patient, which is at times very great. However, by using patience and taking advantage of the little interstices between the jaws, it is always possible to accomplish this. The introduction of the tube is usually easy. The end entering the pharynx sets up reflexly the move- ments of deglutition, so that the instrument of itself enters the oesophagus. A gentle push suffices to make it enter the stomach. Although the large size of the tube renders a false passage almost impossible, the purpose of the third stage is to ascertain that the tube is well in place and has not entered the trachea. Two procedures are used to make sure of this: auscultation at the opening of the funnel and introduction into the tube of several drops of pure water. If the noise produced by the gases of the stomach is heard, and if the water runs down freely, the tube is in place and is not obstructed. Otherwise the tube must be withdrawn and cleaned and the operation recommenced. The liquid nourishment should always be introduced at a low pressure. Its composition may vary accord- ing to individual cases. Milk, eggs, beef -juice, peptones, or vegetable soups usually constitute the basis. Tube-feeding through the nasal passages presents several inconveniences: 120 MANUAL OF PSYCHIATRY. (1) It is painful; (2) It causes quite often irritation and inflammation of the nasal mucosa; (3) The small dimensions of the tube render its intro- duction into the larynx easy, and do not allow the use of any but perfectly liquid food. This method of feeding should, therefore, not be resorted to except in special cases, such as those of buccal affections interfering with the introduction of the tube by the mouth. Not infrequently after tube-feeding the patient rejects the contents of the stomach either spontaneously or by a voluntary effort. This may often be prevented by throwing a few drops of water at his face. In cases of obstinate vomiting the irritability of the stomach mucosa may be diminished by introducing with the liquid food several drops of a solution of cocaine. It may be useful to precede the feeding by lavage of the stomach. PART II. SPECIAL PSYCHIATRY. CLASSIFICATION. Pathological anatomy is the only criterion that enables us to establish in the diseases of an organ categories corresponding to reality. The lesions of most of the psychoses being unknown, each school assumes the right to create a classification corresponding with its tendencies, which may be more or less ingenious, but is necessarily artificial. Of all those offered to us by psychiatry it would be best to select the most practical, the most convenient, and the one which in a given case would enable us most easily to establish the prognosis and to institute the treatment. The classification of Kraepelin appears to me to present great advantages from this stand- point. I shall therefore adopt it here with some modifications, which shall be indicated in the course of this work. The following are the morbid entities described in this manual, enumerated in the order which I propose to follow. 121 122 MANUAL OF PSYCHIATRY. I. Infectious psychoses: Febrile delirium; Infectious delirium; Hydrophobia. II. Psychoses of exhaustion: Mental confusion; acute delirium. III. Toxic psychoses: (a) Acute: Pathological drunkenness. (b) Chronic: Alcoholism; Morphinomania ; Cocainomania. IV. Psychoses of autointoxication: (a) Acute: Uraemia; (b) Subacute: The polyneuritic psychosis. (c) Chronic: Myxoedema; Dementia prsecox; chronic delirium; General paresis. V. Psychoses dependent upon so-called organic CEREBRAL AFFECTIONS^ Arteriosclerosis; cerebral tumors; cerebral syphilis; hemorrhages; softenings. VI. Psychoses of involution: Affective melancholia; Senile dementia. VII. Psychoses without a well-determined eti- ology, WHICH ARE APPARENTLY BASED UPON A MORBID PREDISPOSITION *. Manic depressive insanity; Paranoia. CLASSIFICATION. 123 Constitutional psychopathic conditions: Mental instability; Sexual perversions and inversions; Obsessions. VIII. Psychoses based upon neuroses: Epilepsy; Hysteria. IX. Arrests of mental development: Idiocy and imbecility; Moral insanity. CHAPTER I. DELIRIA OF INFECTIOUS ORIGIN. 1 The mental disorders which appear in the course of infectious diseases are brought about by the combined action of several factors: elevation of temperature, congestion of the nervous centers, and poisoning of these centers by microbic toxines. The most important factor appears to be the poisoning of the nervous centers. One cannot fail to notice the striking clinical resem- blance existing between the toxic deliria, properly so called, and the infectious deliria; indeed the resemblance is so close that without the somatic symptoms peculiar to each condition it would be difficult or even impossible to make the differentiation. Notes on such cases almost always describe the same symptoms: clouding of consciousness, confusion, numerous illusions and hallucinations, motor agitation. Moreover, the infection itself, independently of hyperpyrexia and probably of any meningeal lesion, may cause grave mental disorders (infectious delirium proper) which can only be explained by a toxic action. 1 Klippel et Lopez. Du reve et du delire qui lui fait suite dans les infections aigues. Rev. de Psychiatrie, April 1900. — Desvaux. Delire dans les maladies aigues. These de Paris, 1899. 124 DELIRIA OF INFECTIOUS ORIGIN. 125 After the description of febrile delirium I shall say a few words with regard to infectious delirium proper. I shall also give a brief description of the mental dis- orders of hydrophobia, which, though, like the preced- ing, they belong to the group of infectious psychoses, merit a special description on account of their constancy and their peculiar aspect. Febrile delirium. — In febrile affections the psychic disorders are usually limited to a slight degree of cere- bral torpor and of irritability of humor. Slight noc- turnal agitation, a few illusions, and some delusions form the imperceptible transition to the graver cases in which the true delirium appears. This consists essentially in a more or less profound clouding of consciousness associated with vague delusions, multiple psychosensory disorders, and excitement which is at times very marked. The delirium is essentially variable and mobile, at times pleasant, at others painful; the psycho-sensory disturbances are of the combined form with a pre- dominance of illusions and hallucinations of sight. The images and scenes follow each other as in a dream, of which they seem to be a continuation (dream delirium). The patient imagines he is in the country, in the theater, in a church; pompous processions march past him amidst the sounds of music and the perfume of flowers and censers; he converses with imaginary persons, defends himself against assassins, rejects a glass of milk offered him, thinking that it is poison. Often under the influence of his hallucinations he strikes at the air and attempts to get out into the street or to pass through the window, which he takes for the door. 126 MANUAL OF PSYCHIATRY. However, as during a dream, the subject may by a sudden and energetic call be transported from the imaginary world into the real one. Such periods of lucidity are in general but transitory. Often, chiefly in the beginning of all forms and through the entire course of the mild forms, the delirium disappears in the morning to reappear in the evening and to last during a portion of the night. The prognosis depends less upon the intensity of the delirium than upon the physical symptoms which accom- pany it. As a rule all febrile affections complicated with intense delirium should be considered as grave. In fatal cases the delirium gradually subsides and coma replaces the excitement. Febrile delirium, like acute alcoholic intoxication, is an excellent criterion for judging the resistance of the brain: the greater the predisposition to mental disorders and the more marked the degeneration of the subject the more likely it is for delirium to occur under such circumstances. Like alcohol, the microbic poisons and the toxic products of the organism act most readily upon brains the equilibrium of which is least stable and therefore most easily disturbed. The treatment is that of the infectious disease. Strict watching is indicated. Cold baths are often very effica- cious in relieving the mental disorders. Infectious delirium proper. — Kraepelin and Asch- affenburg have described under the name of infec- tious delirium mental disorders which supervene in the course of an infection without the fever being particularly intense or even before the fever appears (Initialdelirium). DELIRIA OF INFECTIOUS ORIGIN. 127 Infectious delirium is met with chiefly in typhoid fever, in variola, and in typhus fever. The symptoms sometimes take the form of maniacal excitement, more often that of acute confusional insanity or of hallucina- tory delirium. The mental disorders of hydrophobia. — Almost always these appear as the first symptoms of the disease. Long before the onset of the hydrophobic symptoms proper, even when the patient is unconscious of the threatening danger, he becomes depressed, gloomy, seclusive, and has occasional attacks of anxiety. Some- times, pressed by an irresistible impulse, he becomes extremely restless, walks or runs about for hours at a time, and finally returns home more tranquil, relieved for a time: it seems that the morbid irritation of the motor zones is calmed. Very prominent also are the inexplicable changes of the emotional state: the sudden outbreaks of affection or of joy, contrasting strikingly with the background of depression and in- difference. The sleep is interrupted by sudden starts and dis- turbed by nightmares. The emotional disorders persist through the entire duration of the disease. But, except during the spas- modic seizures, consciousness remains intact up to the very last. In a few rare cases a continuous delirium is established, assuming various forms: mystic, per- secutory, melancholy, etc. During the paroxysms there is very severe anxiety, agitation reaching almost the intensity of furor, and psycho-sensory hyperesthesia which in extreme cases gives rise to hallucinations: the patient sees flowers. 128 MANUAL OF PSYCHIATRY. fantastic forms, hears the noise of firearms, the sounds of trumpets, etc. The phenomena of excitement gradually become less marked and finally disappear with the onset of the paralytic stage. The diagnosis bases itself upon the existence of psycho- sensory hyperesthesia, and especially upon the charac- teristic spasms of hydrophobia (pharyngeal spasms). The treatment, which is but palliative, consists in the administration of antispasmodics in large doses. CHAPTER II. PSYCHOSES OF EXHAUSTION. PRIMARY MENTAL CONFUSION, ACUTE DELIRIUM. Well described by Georget and by Delasiauve under the name of " stupidity," primary mental confusion has only recently been brought into prominence again through the labors of Chaslin and of Seglas. 1 The fundamental element of this morbid entity is the mental confusion which is primary, profound, and constant. Essential symptoms. — After several days of ill-defined prodromata such as headache, anorexia, and change of disposition, the disease sets in, manifesting itself by psychical and physical symptoms. A. Psychical symptoms. — These are the symptoms of intellectual confusion, more or less marked and more or less pure according to the gravity of the disease : Clouding of consciousness; Impairment of attention; Sluggish and disordered associations of ideas; Insufficiency of perception ; Aboulia, characterized by constant indecision and by slowness and uncertainty of the movements. 1 Chaslin. La confusion mentale- primitive. — Seglas. Legons cliniques. 129 130 MANUAL OF PSYCHIATRY. The state of the automatic psychic functions varies according to the form of the disease : the mental automa- tism may be relatively unaffected (simple mental con- fusion), exaggerated (delirious mental confusion), or paralyzed like the higher mental functions (mental confusion of the stuporous form). B. Physical symptoms. — The physical symptoms are constant and "are the expression of the general prostra- tion, exhaustion, and ill-nourishment v (Seglas). Loss of flesh is an early and a very marked symptom. It is caused by insufficient alimentation, digestive dis- orders, and especially by a defective assimilation of nutritive matter. Fever sometimes exists, chiefly at the onset; in some cases, especially in the stuporous form, there may be subnormal temperature. A small low tension pulse, feeble and at times irregu- lar heart sounds, sluggishness of the peripheral circula- tion, cyanosis of the extremities, and oedema are among the manifestations of the general atony of the cardio- vascular apparatus. The appetite is abolished, the tongue coated; the process of digestion is accompanied by painful sensa- tions; constipation is always present. Frequently there is a slight albuminuria. The sleep is diminished, often replaced by a dreamy state analogous to that of the infectious diseases. Primary mental confusion may be met with in four principal forms, differing in their gravity and in the predominance of one or the other class of symptoms: Simple mental confusion; Delirious mental confusion; PSYCHOSES OF EXHAUSTION. 131 Mental confusion of the stuporous form; Hyperacute mental confusion (acute delirium). Simple mental confusion. — The essential symptoms which have been enumerated above are encountered here in their purest form. The phenomena of psychic paralysis are of a moderate degree of intensity and the automatic mental functions are unaffected. The patient is often more or less conscious of his con- dition; he observes that a change has taken place in him. "I am losing my head. . . . My mind is a blank " He perceives his mental disability and complains of being unable to gather or direct his thoughts or to evoke reminiscences — even those that have left a very strong impression. The mental disability indecision, and insufficiency of perception bring about a state of constant bewilderment. The patient is constantly repeating the same questions and the same exclamations: "Who is there?... Who has come? . . . Who are you? . . . Everything around me has changed. " He does not recognize his surroundings, or if he does, it is with uncertainty. He is not certain about the identity of those about him; his bed appears queer to him, his own body seems to him to be changed, scarcely recognizable. In more advanced degrees we find complete disorientation, which is a constant symp- tom, at least in cases of a certain gravity. The reactions are slow, undecided; the movements awkward and clumsy. The mental automatism remaining intact, those men- tal operations which require no effort and no interven- tion of the will can still be properly performed. Thus one may obtain from the patient a certain number of 132 MANUAL OF PSYCHIATRY. relevant and accurate replies concerning his age, occu- pation, residence, etc. But these replies are always given mechanically; they are brief and abrupt, and can be elicited only by putting the questions energetically and concisely. This simple and, so to speak, schematic form of primary mental confusion is quite rare. Delirious form. — This form, much more frequent than the preceding one, owes its peculiar aspect to a more or less marked exaggeration of the activity of the mental automatism, which gives rise to : (a) flight of ideas and incoherence; (6) delusions and psycho-sensory disorders; (c) more or less excitement. The delusions present no systematization, as for this at least a relative lucidity is necessary. They assume different forms, which often interchange in the same subject; ideas of grandeur, transformation of the per- sonality: melancholy ideas, ideas of persecution. Pain- ful delusions are the most common. Sometimes the ideas are absurd, like those of senile dements or of gen- eral paretics. The psycho-sensory disorders consist sometimes in agreeable but more often in painful illusions and hallu- cinations of all the senses, though most usually of vision and of hearing. They may combine so as to create an imaginary world which is essentially mobile and change- able, or, on the contrary, they may coexist without any apparent correlation. Occasionally the incessant illusions and hallucina- tions impart to the patient a peculiar expression. Most cases described under the name of hallucinatory delir- ium should properly be included in this form of mental confusion. PSYCHOSES OF EXHAUSTION. 133 The emotional tone is variable, governed to some extent by the delusions. However, one often finds, in spite of very active delirium, a striking indifference, so that a certain discord exists between the delusions and the emotions. The agitation is not always due to the delusions and psycho-sensory disturbances. As in dementia precox, so also in this condition the patient may give vent to cries and motor discharges that are purety automatic and without any apparent purpose. Mental confusion of the stuporous form. — Here the psychic paralysis involves not only the higher mental faculties, but also the automatic psychic functions. The limbs are motionless, the eyes dull, and the face expressionless; the mouth may be half open and the saliva dribbling away uncontrolled. The patient fails to react even to the strongest stimulation, or he may react but very feebly. Cataleptic attitudes with dilated pupils are quite often seen. Hyperacute form (acute delirium). — This form is char- acterized by the intensity of the delirium and of the agitation on the one hand, and by the gravity of the general symptoms on the other hand. The patient, attacked by numerous hallucinations, either painful or agreeable and accompanied by erotic tendencies, becomes completely disoriented and wildly excited: he shouts, sings, jumps out of bed, strikes the walls, and attacks those about him. The eyes are in- jected, the respiration panting, the skin covered with perspiration, the temperature elevated, and the pulse is small and often rapid and irregular. These signs point 134 MANUAL OF PSYCHIATRY. to the gravity of the condition. In fatal cases the patient rapidly passes into coma and dies in a few days. In favorable > cases the agitation gradually disappears, the patient regains his sleep, and recovery finally takes place; this favorable termination is rare. Duration, course, and prognosis of primary mental confusion. — The duration of the attack varies from sev- eral days to a few months. The curve representing its intensity is rapidly ascendant, then it remains stationary for some time without oscillations, and finally descends gradually. The period of descent often presents irreg- ularities on account of recrudescences of the disease, which are usually mild. Such is the course of favorable cases, which fortu- nately are the most frequent (excluding acute delirium) . Recovery is complete. But the patient's recollection of the events which have taken place during the illness is vague or even absent. The period of convalescence is very protracted. Suicide is rare even in the depressed forms; the aboulia is the patient's safeguard. In unfavorable cases death occurs from collapse in the hyperacute form, and from cachexia or from some complication (pneumonia, subacute tuberculosis, in- fluenza, infections following traumatisms) in the less rapid cases. Diagnosis. — The principal elements of diagnosis are: the appearance on mental confusion at the onset of the disease; the possibility of obtaining correct replies to simple and energeticalfy put questions; the state of physical exhaustion, and the existence of the special etiological factors, which we shall mention further on. PSYCHOSES OF EXHAUSTION. 135 Many other psychoses may resemble primary mental confusion because they may be complicated by secondary mental confusion. The points of differential diagnosis will be indicated in the respective chapters devoted to the consideration of these psychoses. Pathological anatomy. — The lesions of primary mental confusion are of two kinds: inflammatory and degenerative. The former, w T hich are most prominent in the severe cases, consist in congestion and diapedesis in the nervous centers. The latter are more constant, and consist in degeneration of the nerve-cells, which is demonstrable by Nissl's method. 1 Etiology. — All factors capable of bringing about a rapid and profound exhaustion of the organism occur in the etiology of primary mental confusion: physical and mental stress, painful and prolonged emotions, but especially grave somatic affections. The puerperal state, through the exhaustion which it entails as well as through the nutritive disorders and infections by which it is sometimes complicated; the infectious diseases (typhoid fever, the eruptive fevers, influenza, cholera); profuse hemorrhages; inanition, etc., are' among the causes frequently found in the history of the disease. How is the action of these factors to be explained? Two hypotheses are possible. According to the one, that of Binswanger, the general 1 Ballet et Faure. Contribution a Vanatomie pathologique de lo psychose polynevritique et certaines formes de confusion mentale primitive. Presse med., Nov. 30, 1898. — Maurice Faure. Sur les lesions cellulaires corticales observees dans six cas de troubles mentaux toxi-infectieux. Rev. neurol., Dec. 1899. 136 MANUAL OF PSYCHIATRY. exhaustion of the organism brings about a deficient cerebral nutrition the clinical expression of which is primary mental confusion. According to the other, advanced by Kraepelin, the causes enumerated above bring about disturbances in the nutritive changes and determine the production of toxic substances which, acting upon the cerebral cells, give rise to an intoxication psychosis: primary mental confusion. Perhaps both causes are at work simultaneously. In either case exhaustion constitutes the essential cause of the affection and the term "Exhaustion Psychosis'' is therefore perfectly applicable to it. Treatment. — During the entire acute period of the disease rest in bed should be rigorously enforced. Proper alimentation is of great importance. A re- constructive diet better than all medication sustains the patient's strength and even calms the agitation. Milk, eggs, chopped meat, and meat-juice should form the basis of the diet. In cases of sitiophobia one must resort without hesitation to artificial feeding; these patients cannot with impunity be allowed to fast. Injections of artificial serum are of great service and of easy application. The necessary apparatus consists chiefly of a glass funnel, a soft-rubber tube, and a slender trochar. Ordinarily 300-500 grams of Hay em's serum may be injected every day or every second day. The most important results of this treatment are the rising of the blood pressure and the diuresis. 1 1 Cullerre. De la transfusion sereuse soua-cutanee dans les PSYCHOSES OF EXHAUSTION. 137 Moderate physical exercise, life in the open air, read- ing, and light and brief mental work accelerate the course of convalescence. 1 psychoses aigues avec auto-intoxication. Prog, med., Sept. 30, 1899. — Jacquin. Du serum artificiel en Psychiatric Ann. med. psych., May-June, 1900. 1 We have intentionally omitted the mental disorders of chronic exhaustion. They form a part of the symptomatology of neuras- thenia, for a description of which the reader is referred to works on neurology. CHAPTER III. PATHOLOGICAL DRUNKENNESS. (acute alcoholic intoxication). The term drunkenness is here used to designate the nervous and mental symptoms by which acute alcoholic intoxication manifests itself. The predisposition to the state of drunkenness, quite variable in different subjects, is a part of the general tendency of the individual toward nervous and mental disorders. "It may be truly said that alcohol is the touchstone of the equilibrium of the cerebral functions." 1 Drunkenness is somewhat schematically divided into two stages: (1) excitement, and (2) paralysis. In re- ality paralysis is present from the begininng, but in the first stage it is limited to the highest psychic func- tions and is masked by the intensity of the automatic phenomena, so that it does not become evident until the second stage, when all the nervous and mental functions become involved in the paralysis. First Stage : Excitement. — Psychic inhibition, the first manifestation of the paralysis, is seen in the slow association of ideas, the distraction, and the insuffi- ciency of perception. The automatism is apparent from the disconnected conversation, which may show 1 F6r6 La Famille nevropathique. Paris. F. Alcan. 138 PATHOLOGICAL DRUNKENNESS. 139 a true flight of ideas, the abnormal pressure of activity, the more or less marked morbid euphoria and irritability, the impulsive character of the reactions, and the extremely voluble speech. The moral sense and the regard for common conventionalities gradu- ally disappear, and the patient may commit ridiculous, repugnant, offensive, or even criminal acts. Second Stage: Paralysis. — Paralysis, confined in the preceding stage to the sphere of the higher psychic functions, now attacks the automatic functions. The movements are awkward and clumsy, the speech indis- tinct, and the gait unsteady. Gradually the patient falls into a profound, sometimes comatose, sleep, — the final stage of the attack, — from which he awakes lucid but with a confused recollection of what has passed and with a pronounced sensation of mental and physical fatigue. Such is, rapidly sketched, the aspect of common drunkenness. From the accentuation or obliteration of certain features result the diverse abnormal or patho- logical forms. Comatose drunkenness. — The phenomena of excite- ment are either absent or very transient. From the beginning the paralysis affects the entire brain. The patient sinks and remains inert and insensible for several hours. His face is congested. Gradually the comatose state is replaced by sleep, from which the patient awakes without any recollection whatever of the occurrences immediately preceding his intoxica- tion. Sometimes the pulse becomes small, the heart weak, the breathing labored, and in some cases, which are fortunately rare, the patient dies in collapse. 140 MANUAL OF PSYCHIATRY. Maniacal drunkenness. — Here the paralysis occupies a secondary position and the excitement dominates the scene. The phenomena of agitation generally develop very rapidlv. All of a sudden the drunkard, while yet at the saloon-keeper's bar, is seized with an outbreak of furious madness without any apparent cause or provocation; he breaks objects and furniture, becomes noisy, and threatens and attacks those about him. The extreme clouding of the intellect shows that, in spite of appearances, "psychic activity takes but a very small part in the production of the outbreak/' and that " subjugated by this automatic development of psycho-motor activity it disappears entirely." 1 Almost always numerous psycho-sensory disorders (hallucina- tions and illusions) are associated with the clouding of the intellect and the excitement. The attack terminates in profound sleep- This, as in the preceding form, is followed by an almost com- plete amnesia. Convulsive drunkenness. — The maniacal form of drunkenness resembles closely the delirious attacks of epilepsy. The relation between epilepsy and acute alcoholic intoxication is rendered still more apparent by the fact that drunkenness may clinically assume the aspect of an epileptic seizure. This is explained by the convulsive properties of alcohol, which have been demonstrated experimentally. Attacks precisely like those of essential epilepsy may supervene in the course of common drunkenness. In all cases they immediately follow the alcoholic excesses, differing in 1 Gamier. La folie a Paris. PATHOLOGICAL DRUNKENNESS. 141 this respect from those epileptiform seizures which supervene in the course of chronic alcoholism. Delusional drunkenness. — This curious but rare form has been well studied by Gamier. The delusions are extremely variable: ideas of persecution, ambitious ideas, depressive ideas with suicidal tendencies, etc. Delusional drunkenness is encountered only in pro- foundly degenerated individuals. Treatment. — This of course varies with the different forms. Maniacal or delusional drunkenness requires strict watching and immediate isolation; the comatose form requires the use of external and internal stimu- lation (friction, ammonium, ether, caffein). CHAPTER IV. CHRONIC ALCOHOLISM. Chronic alcoholism manifests itself: (1) in per- manent symptoms (the chronic stigmata of alcoholism), and (2) in episodic accidents. I. Permanent Symptoms. The permanent symptoms are psychical and physical. A. PSYCHICAL SYMPTOMS. There is an enfeeblement of all the psychic functions. Intellectual sphere. — Intellectual activity and the ca- pacity for work are diminished. The patient becomes dull, negligent, and clumsy. The disorders of memory consist in a definite retro- grade amnesia by destruction of impressions, associated with a more or less marked anterograde amnesia. The former follows the general law of amnesia. Its course is slowly progressive; but it is rare for it to reach as complete a development as it does in general paresis. The anterograde amnesia renders it difficult or even impossible for the patient to acquire new impressions; thus the stock of ideas becomes more and more impover- ished. 142 CHRONIC ALCOHOLISM. 143 The judgment is constantly affected: the patient realizes but imperfectly his condition and the importance and significance of his actions. Emotional sphere. — As in most affections with a basis of intellectual enfeeblement, we find in chronic alcoholism indifference associated with morbid irrita- bility. The chronic alcoholic is not at all concerned with his ruined business, the misery of his family, or the compromise of his honor. Only the desire for alcohol can still arouse him from his mental torpor. The atrophy of the moral sense, which in these cases goes hand in hand with the general indifference, is such that in order to procure his favorite drinks the patient does not hesitate to make use of the most unscrupulous means and to associate with the vilest characters. If he still works, he spends his entire salary for drink. If he does not work, as is the rule in such cases, he accumu- lates debts in the lowest of drinking- dens, extorts from his relatives what little money they may have earned by hard labor, and he may even resort to stealing. The irritability and the impulsive tendencies give rise to violent, terrible outbursts of anger, and often to assaults and attempts at murder. Delusions may appear at times, almost always those of persecution or of morbid jealousy. When they become more developed and acquire a certain fixedness they constitute the alcoholic systematized delirium which we shall study later on. Still the patient's obscure consciousness presents at times a temporary lucidity. Strong remonstrances of friends or grave disorders of the general health 144 MANUAL OF PSYCHIATRY. may give birth to repentance. The unhappy subject regrets his excesses, declares himself a great sinner, swears by all that is holy that he will not take another drop of wine or liquor, and announces his intention to join a temperance association. These good resolutions are carried out for several days, weeks, or even months ; but almost always the patient falls again: his feeble will gives way and he can struggle no longer. He is in a vicious circle: "he drinks because his will is weak, and his will is weak because he drinks. When they attain a certain degree of intensity, the mental disorders which I have sketched constitute alcoholic dementia. Alcoholic dementia is slowly progressive. It takes years to become fully established. Moreover, — and this is a highly important feature, — it ceases to progress with the cessation of the alcoholic excesses. B. PHYSICAL SYMPTOMS. The sleep is diminished, restless, disturbed by un- pleasant dreams. The patient is apt to dream that he is at his occupation (occupation-dreams); the work is pressing, but in spite of his diligence he is always behind and the results are unsatisfactory. At other times ver- itable dramas are enacted: assassins pursue him, rats run at him, snakes and monstrous spiders creep over him (zoopsia). These dreams present all the characteristics of delirium tremens, which has been aptly called a pro- longed dream. Sometimes the patient wakes up in the midst of his nightmare with his head heavy, the body covered with perspiration, still doubting the inanity of his terrors. CHRONIC ALCOHOLISM. 145 Attacks of vertigo and flashes of light, which often precede and usher in apoplectiform attacks, occur as the result of the disordered condition of the cerebral circulation. The motor disturbances consist in muscular weakness, chiefly marked in the lower extremities, a tendency to lassitude, and a constant tremor affecting especially the tongue and the hands ; the digital tremor is rendered very apparent when the patient holds out his hand and slightly spreads out his fingers: it is a fine, horizontal tremor, not very rapid. The tendon reflexes are sometimes exaggerated, but much more frequently diminished or abolished ; the cuta- neous reflexes are usually exaggerated (plantar reflex), especially in intoxications by the essences (absinthe) ; sometimes they are abolished; the pupils are paretic and sometimes slightly myotic. Occasionally there is a slight degree of strabismus or of ptosis. The vision is frequently disordered, due to retrobulbar neuritis; there is diminution of the acuteness and there may be a "central scotoma having the shape of an ellipse the long axis of which is horizontal" (Babinski). Cutaneous sensibility is reduced in the large majority of cases; the hypoaBsthesia is often unilateral; in such cases it is associated with other hysteroid manifesta- tions: hysterogenic zones, globus hystericus, absence of the pharyngeal reflex. Among the disorders of deep sensibility are to be noted numbness, tingling, hypersesthesias of portions of muscles which are painful on pressure or are cramped; dull pains with lancinating paroxyms resembling the lightning pains of tabes. 146 MANUAL OF PSYCHIATRY. The motor and sensory disturbances, whatever their distribution may be, are always, due to peripheral poly- neuritis which is a constant manifestation of chronic alcoholism. The gastro-intestinal disorders are manifested b}^ ano- rexia, pyrosis, coated tongue in the morning, slow and painful digestion, and constipation. The liver is often enlarged, and so is also the spleen. The true alcoholic cirrhosis is sometimes met with, but assumes a special aspect, the principal peculiarity of which is the absence of ascites. Diagnosis. — Chronic alcoholism is to be differentiated chiefly from those diseases in which there is intellectual enfeeblement. The question of differential diagnosis will be considered in connection with each of these : general paresis, senile dementia, and dementia prsecox. Prognosis. — This is always grave. The symptoms of intellectual enfeeblement once established are not likely to become abated. The timely suppression of alcohol prevents their appearance or, if they are already present, arrests their progressive course. Unfortunately this is very difficult to accomplish. Pathological anatomy. — The arterial system is the seat of atheromatous degeneration the intensity and extent of which are variable; it affects especially the arteries of the cerebrum. Atheromatous changes in the arteries at the base are frequent, though not constant. The arterioles and capillaries always present a state of degeneration characterized by the presence of granular masses containing nuclei, which indicate their cellular origin. The nerve-cells undergo " r a certain degree of granulo- CHRONIC ALCOHOLISM. 147 pigmentary and fatty degeneration." 1 The nerve- fibers, especially the tangential and commissural fibers, are partially atrophied. The extent of the lesions in the nervous elements is proportionate to that of the intellectual enfeeblement. Therefore it is especially marked in cases of advanced dementia. The organs of the vegetative functions present the usual lesions of alcoholism: myocarditis, interstitial nephritis, alcoholic gastritis, fatty degeneration of the liver. The hepatic lesions have become of special in- terest since Klippel has shown that they are the imme- diate cause of certain deliria occurring in alcoholics. Etiology. — How does one become an alcoholic? This question resolves itself into two distinct inquiries, as follows : 1. Why does a given individual drink alcohol in injurious doses? 2. Why are certain nervous systems more susceptible than others to the poisonous action of alcohol? It would require a volume to reply fully to the first question; indeed, it would mean a solution of the gigantic problem of alcoholism in its social relations. According to Kraepelin, heredity seems to play a cer- tain role. The tendency to alcoholic excesses is trans- mitted to descendants. Fere also states that "to be- come an alcoholic one must be alcoholizable ; the mere indulgence in fermented beverages is not in itself suffi- cient." This factor is of some importance, though slight when compared to that of the social factors. 1 Klippel. Du delire alcoolique. Mercredi medical, Oct. 1893. 148 MANUAL OF PSYCHIATRY. Among the latter the most powerful is undoubtedly the ignorance of the people as to the true action of alcohol, as well as the false, disastrous notion prevailing among all classes of society that alcohol gives force and is therefore indispensable to the workingman for the performance of hard labor. Though it is to-day a well-established fact in the medical and scientific world that alcohol produces but an illusion of force, and that the sense of increased energy which it gives is but a morbid subjective phenomenon, this idea is still looked upon by the public as an innovation of doubtful cer- tainty, "an invention of the doctors.'/ To ignorance is joined the element of suggestion. There can be no doubt that many individuals begin to drink by chance or by example. For a laborer it is almost impossible in his social intercourse to escape alcoholism, even though he may be aware of its dangers. His comrades drag him into the saloons, which constitute perpetual temptations on his way. Refusal to accept their invitations exposes him to their ridicule and to their ill-treatment, and condemns him to the isolation of a social outcast; here, as everywhere else, u to do as others do" is the great principle that governs the indi- vidual and obliges him to conduct himself against his own interest and even against his own inclinations. Among the social factors there are a great many special factors one of which deserves special mention, namely, grief. Some alcoholics abandon themselves to drink on account of financial ruin, others because of domestic unhappiness, etc. However, it is to be remembered that quite often patients claim their misfortunes to have been the cause of their intern- CHRONIC ALCOHOLISM. 1 19 perance, while in reality they are the effect. The drunkard pretends that he drinks to find relief from his domestic griefs, while in fact his intemperance has caused them. We now have to answer the second question: Why does alcohol exert a rapid and intense action upon certain nervous systems, while others resist success- fully much greater excesses? — It is here that the indi- vidual predisposition comes into play. Like the symptoms of acute alcoholism, those of chronic alcoholism appear chiefly in predisposed individ- uals; and the greater the predisposition the more rapidly do these symptoms develop. We see daily in general hospitals patients presenting atheroma of the arterial system, alcoholic cirrhosis, etc., and show- ing but slight if any nervous or mental disorders ; while in insane asylums patients are admitted whose alcoholic excesses have been relatively slight and whose nervous systems have nevertheless already suffered irreparable damage. The quality of the soil is therefore of pri- mary importance. The pathogenic action of alcohol is also favored by all the factors which diminish the resistance of the organism, such as stress, grief, want of sleep, and acute or chronic infectious diseases (tuberculosis). Thus we often encounter, associated in the same subject, the abuse of alcohol, predisposition, and debilitating influences. It would be useful to know which among the alcoholic beverages produce so great a toxic action as to be particularly responsible for the production of alcoholism. Clinical evidence seems to show that the principal 150 Manual of psychiatry. factor in alcoholism is the quantity and not the quality of the beverage ingested. The experiments of Joffroy and Serveaux have shown clearly that alcoholic intoxi- cation is due to ethyl alcohol itself, and not to the impurities often associated with it. Therefore all fermented beverages may cause alcoholism: liquors, alcoholic tonics, wines, beers, ciders, the alcohol of wines as well as that of substances used in the indus- tries. However, "a given quantity of alcohol is the more toxic the more concentrated it is; for this reason the stronger alcoholic beverages play a prominent role in the production af alcoholism/' 1 The essences, particularly the essence of absinthe, have been claimed to be especially prone to produce alcoholic epilepsy. This opinion, based chiefly upon experiments, has not been altogether confirmed clin- ically. Treatment. — The most important indication in the treatment is complete abstinence from alcohol in any form. This in well-established cases of chronic alco- holism can be carried out only in an insane-asylum or, still better, in a special institution for inebriates. 2 1 Antheaume. De la toxicite des alcools. These de Paris, F. Alcan 1897. This work contains the results of the experiments of Joffroy and Serveaux. 2 Serieux. Les etablissements pour le traitement des buveurs en Anghterre et aux Etats-Unis. Projets de creation d'asiles d'alcooliques en Autriche et en France. Bullet, de la soc. de med. ment. de Belg., 1895. — By the same author. L' assistance des alcooliques en Suisse et en Allemagne. Ibid. Also L'Asile d'alcooliques de departement de la Seine. Ann. med. psych., 1895, Nov.-Dec CHRONIC ALCOHOLISM. 151 II. Episodic Accidents. The episodic accidents of chronic alcoholism may be acute or subacute, and are of four kinds: delirium tremens, alcoholic systematized delirium, the poly- neuritic psychosis, and alcoholic epilepsy. The polyneuritic psychosis is to be studied later on; the symptoms of this disease are the same whether it results from an infection, from an autointoxication or from the abuse of alcohol. Alcoholic epilepsy presents the same clinical features as essential epilepsy. The convulsions often follow alcoholic excesses, from which they are separated by an interval of twenty-four hours and sometimes longer. They may also be associated with acute intoxication, so that they are dependent at once upon alcoholic epilepsy proper and upon the acute intoxication. The prognosis is variable. Though the convulsions usually disappear with the suppression of alcohol, still in many cases they persist and the subject behaves like an or- dinary epileptic. Alcoholic intoxication thus resembles in its after effects certain infectious diseases, 1 notably ty- phoid fever, which are apt to leave epilepsy as a sequel. Analogous to the states of obscuration and the absences of epilepsy are the states of transient sub- consciousness which are occasionally met with in alcoholics, and in the course of which the patients may commit criminal acts. 2 1 Dide. Valeur de la fievre typhoide dans Vetiologie de I'epilepsie. Revue de medecine, Feb. 1899. 2 Moeli. Ueber die vorubergehenden Zustcinde abnormen Bewusst- seins in Folge von Alkoholvergiftung und deren forensische Be- deutung. Allgem. Zeitsch. fur Psychiat., Nos. 2 and 3, 1900. 152 MANUAL OF PSYCHIATRY. Of delirium tremens and of alcoholic systematized delirium we shall make a more detailed study. A. DELIRIUM TREMENS. The prodromata consist in an accentuation of the symptoms of alcoholism. The sleep is more than ever disturbed by nightmares, preceded by painful h} T pna- gogic hallucinations, and reduced in the last days before the attack to a vague somnolence. Violent headaches and a sort of inexplicable uneasiness usher in a grave affection. Frequently the patient, divining the cause of the threatening storm, suppresses the alcohol; in vain, however, for the attack almost alwa}^s breaks out in spite of the tardy abstinence. Psychic symptoms. — These were admirably analyzed years ago by Lasegue and more recentty by Wernicke. Three chief symptoms dominate the scene: disorder of consciousness, hallucinatory delirium, and motor agi- tation. The disorder of consciousness involves exclusively the notion of the external world, i.e., the allopsychic orien- tation, leaving intact the notion of the personality, i.e., the autopsy chic orientation (Wernicke). The illusions and hallucinations are constant and at times incessant. They present two general character- istics: (1) they are painful; (2) they are combined in such a manner as to form complete scenes and create around the patient a whole imaginary and often fan- tastic world. They affect all the senses, but especially the sense of sight. The visions of delirium tremens are always mobile CHRONIC ALCOHOLISM. 153 and animated. They form an uninterrupted succession of strange, painful, or terrifying scenes. Two principal forms of the delirium may be distin- guished: (a) occupation delirium, and (b) persecutory delirium. (a) Occupation delirium. — The patient thinks that he is amongst familiar surroundings and imagines himself at his usual occupation. The hallucinations possess re- markable distinctness and intensity: the cab driver leads his horses, urges them on, whips them, and runs over pedestrians who do not get out of his way quickly; the cafe waiter waits upon his clients, receives the money, and shows them to vacant seats. (b) Persecutory delirium. — The psycho-sensory disor- ders assume a terrifying character. Grimacing and horrible forms are seen in the folds of the curtains, upon the window-panes, or upon the walls. Assassins come out of every corner; the patient hears clearly their threats and abuses and describes their costumes and their weapons. He sees frightful and fantastic animals ; rats, snakes, gigantic tigers fill the room, constantly changing their shapes and throwing themselves upon the wretched subject, who repels them with desperate efforts. An odor of poison proceeds from all sides; the food has a putrid taste. The motor activity is at times very violent. The pa- tient walks to and fro in the dormitory or in his room, seeks his clothes, strikes the walls to open a pass- ageway for his escape, emits cries of terror; or he whistles and sings, assuming in the intervals a conver- sational tone, as he imagines himself surrounded by his acquaintances. The movements ; though sudden and 154 MANUAL OF PSYCHIATRY. awkward, always have a psychic origin (Wernicke); it is true that they are determined by imaginary represen- tations and sensations, but they Invariably present the character of "purposeful acts. The patient who believes himself to be in his workshop goes through the regular movements necessary for the performance of his habitual work; another, the victim" of terrifying hallucinations, executes the movements of flight or of defense. On viewing broadly all the preceding symptoms we observe that the hallucinations of delirium tremens are like a vivid mobile dream. Just as a sleeper can be awak- ened, so can the patient be momentarily roused from his delirium by a sudden interpellation. One then obtains correct responses, so that the patient may create the impression of a normal individual. But as soon as he is left alone he relapses into his delirium and agitation. Physical symptoms. — The tremor of chronic alcohol- ism becomes exaggerated so that there is a shaking of the entire body. The speech presents a characteristic tremulousness. At times a slight degree of syllabic stuttering, para- phasia, facial paresis, or even hemiparesis appear, show- ing the participation of the projection centers in the mor- bid process, and thus establishing a point of contact between delirium tremens and general paresis, — the psychic disease in which the projection centers are most profoundly affected. 1 The tendon and cutaneous reflexes are usually exag- gerated. A certain degree of hyperesthesia is the rule. The 1 Bonhoffer. Der Geisteszustand der Alkoholdeliranten, 1897. CHRONIC ALCOHOLISM. 155 morbid irritability of the psycho-sensory centers ex- plains the facility with which it is possible, by a simple suggestion or by slight mechanical stimulation, to bring forth a hallucination, even after the spontaneous psycho- sensory disorders have disappeared (induced hallu- cination's of Liepmann). 1 We encounter also paresthesias and even anaes- thesias. Fever is almost a constant symptom; its presence furnishes an excellent element for prognosis even regardless of all complications. In favorable cases the temperature does not rise beyond 39° C, reaching its maximum towards the end of the second day. Defer- vescence takes place either rapidly or by lysis. In grave cases the temperature rises above 39° or even 40° C. There is aiso to be noted a dyspeptic condition of the digestive tract which is often very marked; usually a slight, sometimes a severe albuminuria, a rapid, full, and bounding pulse which, in grave forms, becomes small and easily compressible. Under these unfavor- able circumstances the general nutrition suffers and there is loss of flesh which becomes very considerable in a few days. Complications. — Among those involving the nervous system the most frequent are epileptiform attacks which often precede by thirty-six or forty-eight hours the onset of delirium tremens. The most formidable as well as the most common complication is pneumonia, Arch. f. Psychiatrie, XXVI. 156 MANUAL OF PSYCHIATRY. which affects chiefly the apex of one or the other lung and assumes from the beginning a grave aspect. Prognosis. — Recovery is the rule. It takes place within four or five days after a deep and prolonged sleep. The sleep may come on suddenly or it may be preceded by a period of calmness. The duration of delirium tremens is sometimes abnormally brief (several hours), and at other times abnormally long (a few weeks or even months). The convalescence is marked at the beginning by a certain amount of confusion which persists for some time and which may or may not be associated with some delusions. Death may occur from exhaustion, from an epilepti- form attack, or from some complication (pneumonia). Diagnosis. — Attacks very similar to delirium tremens are seen outside of alcoholism, notably in senile dementia, in general paresis, and in meningitis at the cerebral convexity. In the latter affection the diagnosis is based upon the existence of specially marked and numerous focal symptoms such as Jacksonian epilepsy, strabismus, etc., upon the condition of the optic disc, and upon the course of the disease. The elements of differentiation from general paresis and from senile dementia will be studied in connection with each of these affections. Pathological anatomy. — To the lesions of chronic alcoholism already considered there are added exudative hypercemia and inflammatory diapedesis, which are the expression of an acute process analogous to that observed in infections. The nerve-cells lose their normal shape and structure, CHRONIC ALCOHOLISM. 157 their angles become blunted, and their chromatophylic granulations are broken up or disappear entirely. The nerve fibers degenerate. These lesions are present throughout the entire cortex, including the centers of projection. It is not rare to find also a certain degree of degeneration in the pyramidal bundles and in the posterior columns; thus we find in the pathological anatomy a confirmation of the relationship which has been clinically shown to exist between delirium tremens and general paresis (Bonhoffer) . The visceral lesions are often dependent upon an infection which may be associated with the alcoholic intoxication, such as influenza, infection by the pneu- mococcus, or typhoid fever. The heart is the seat of a myocarditis which in many of the fatal cases constitutes the immediate cause of death. The liver presents a degeneration that is so frequently met with and at times so pronounced that Klippel x has been led to think that delirium tremens may be the result of an autoinfection of hepatic origin. The lesions of the kidneys are, according to Herz, 2 those of acute parenchymatous nephritis. He states that these lesions are constant. Thus delirium tremens would seem to be nothing but an attack of ursemia to 1 Klippel. Du delire des alcooliques. (Lesions anatomiques et pathogenic Mercredi medical, Oct. 1893. — De Vorigine hepatique de certains delires des alcooliques, Ann. med. psych., Sept.-Oct., 1894. 2 Abstract in Centralblatt fur Nervenheilkunde und Psychiatrie, May, 1898. 158 MANUAL OF PSYCHIATRY. which a special aspect has been imparted by the chronic alcoholism. Pathogenesis. — Delirium tremens is not to be con- sidered as a simple alcoholic intoxication, a sort of belated drunkenness caused by an accumulation of the poison in the organism. Its clinical aspect in fact differs radically from acute intoxication. Moreover, the attack of delirium is apt to break out even after the alcoholic excesses have been suspended for several days. Finally, the patient makes a perfect recovery, even if alcohol is administered to him in large doses during the course of the delirium. Some authors, Wernicke among them, attribute delirium tremens to sudden withdrawal of the alcohol. Experience does not seem to bear out this opinion; we meet daily with inveterate alcoholics in whom complete abstinence does not produce the slightest damage. An important fact upon which Joffroy frequently insists in his lectures is that delirium tremens often breaks out at the occasion of an accidental infection, such as influenza, pneumonia, or suppuration. Thus it seems that the disease is caused by two agencies, alco- holism on the one hand and some accidental affection, most frequently an infection, on the other hand. By what mechanism does their combination produce this effect? — Possibly by determining an autointoxica- tion by insufficiency either of the liver (Klippel) or of the kidneys (Herz). It should be remembered, however, that in many cases the second factor, the accidental infection, is not found. Perhaps, reduced to some disorder possessing CHRONIC ALCOHOLISM. 159 in itself no apparent gravity, such as an attack of gastric indigestion, it passes unnoticed. Treatment. — Rest in bed is very useful and is appli- cable in the vast majority of cases. More so than in any other psychosis, in this disease mechanical restraint is dangerous and is to be prohibited. The weak heart action and the poor condition of the liver and of the kidneys oblige the physician to make but very little use of hypnotics, especially in severe cases. The most serviceable and least danger- ous are chloral and paraldehyde, which, administered in large doses, are of considerable value. They should not be used without previously excluding the likelihood of collapse. Letulle has obtained good results from cold baths. Alcohol in some form was formerly very popular as a factor in the treatment of delirium tremens. This practice is, however, useless, at least in most cases. When the patient's forces decline rapidly alcohol may be given as a stimulant. Caffein and ether in subcutaneous injections often prevent grave cardiac disturbances. The food should be substantial and should be such as to facilitate the elimination of toxines accumulated in the organism. A milk diet admirably fulfills this double indication. Sometimes it is useful to add eggs, and in cases where there is much weakness beef- juice or chopped meat may also be given. B. ALCOHOLIC SYSTEMATIZED DELIRIUM. Alcoholic systematized delirium differs from delirium tremens: (1) in the predominance of hallucinations 160 MANUAL OF PSYCHIATRY. of hearing over those of sight; (2) in the absence of any marked disorders of consciousness; and (3) in its course, which most frequently presents a subacute character. After a rather prolonged prodromal period marked, as in the case of delirium tremens, by an accentuation of the symptoms of chronic alcoholism, the patient becomes uneasy, distrustful, and suspicious. Gradually false interpretations, illusions, and persecutory ideas become established. He does not dare to leave the house, feeling that he is being watched, insulted, or threatened by passers-by or followed by the police. After several days or several weeks at most hallucina- tions of hearing appear followed often by hallucinations of the other senses. The disease very rapidly reaches its highest develop- ment and then presents the following fundamental features : (a) Conservation of lucidity: the patient continues well oriented, understands questions, and answers relevantly. (&) The painful character of the delusions and of the psycho-sensory disorders: ideas of persecution of a vari- able nature : fear of being poisoned or assassinated, ideas of jealousy; imaginary insults or threats; frightful visions, especially marked at night, grimacing figures, ghosts, detectives coming to take the patient into custody, executioners, etc.; a taste or an odor of poison or of faecal matter; sensations of scalding, pricking, or electric currents; motor hallucinations. These latter phenomena, but slightly marked in the majority of cases, point to a grave prognosis when they assume a CHRONIC ALCOHOLISM. 161 certain intensity; they often forebode a very prolonged course of the delirium and indicate the existence of a tendency towards intellectual enfeeblement. Hallu- cinations of taste and smell often cause refusal of food. (c) A tendency to systematization: the subject seeks an explanation and a cause for the persecutions of which he is the subject. However, the systematization is of rapid development and is not always very accurate, so that it resembles but imperfectly that of chronic delirium. (d) A depressed mood and aggressive tendencies: the patient, profoundly irritated, wreaks his vengeance upon innocent victims, being determined to defend himself against the persecutions of his enemies or to escape them by any possible means. If such a patient desires to die it is not, as is the case with other classes of patients, for the purpose of expiating some crime or of finding relief from remorse, but solely to escape the frightful tortures prepared for him by his enemies. Often he transforms his house into a veritable arsenal and, unfortunately, does not limit himself to simple demonstrations, but makes actual use of his weapons. The somatic disorders of chronic alcoholism are all present in this affection. Sleep is diminished and filled with the pathognomic dreams. The urine often contains a trace of albumen, which indicates a defective condition of the renal functions. When ideas of jealousy predominate the affection merits the special name of alcoholic delirium of jealousy. The hallucinations in such cases occupy a secondary position, without, however, being entirely absent in 162 MANUAL OF PSYCHIATRY. any case. The delusions are almost always absurd: the proofs that the patient furnishes of his wife's improper conduct are childish. 1 As a general rule an attack of alcoholic systematized delirium tends towards recovery. This takes place gradually after several weeks or at most several months. The ideas of jealousy are the most tenacious; they may persist for a long time after the suppression of the alcohol. The prognosis is, however, not altogether favorable, firstly because relapses are to be feared, and secondly because each successive attack leaves a noticeable trace upon the intelligence and accelerates the course of alcoholic dementia. It is of great importance to make the differential diagnosis between alcoholic systematized delirium and the other affections in which systematized delusions are encountered, viz., dementia prsecox, chronic delirium and paranoia. The reader is referred to the respective chapters devoted to these diseases for the points of differentiation. The treatment is that of chronic alcoholism. The violent reactions of the patient usually necessitate commitment. Attacks of agitation are to be treated by the usual methods'. 1 Villers. Le delire de la jalousie. Bruxelles, 1899. — Parant. he delire de la jalousie . These de Paris, 1901. CHAPTER V. CHRONIC INTOXICATION BY THE ALKALOIDS. § 1. MORPHINOMANIA. Chronic intoxication by morphine brings about a condition known as morphinism. Morphinism con- stitutes morphinomania when the drug has become a necessity to the organism, so that its suppression causes a train of physical and psychical disturbances known as the symptoms of abstinence. Etiology. — The study of the etiology of morphino- mania involves the consideration of two distinct ques- tions: (1) What individuals are apt to become mor- phinomaniacs? (2) How does one become a morphin- omaniac? (1) What individuals are apt to become morphino- maniacsf Morphine is no longer, as it was formerly, an aristo- cratic poison limited to the upper classes. "Even rural populations are no longer exempt from the con- tagion; and the fault is chiefly with the physicians." 1 Morphinomania is especially frequent among those who, on account of their profession or surroundings, 1 Chambard. Les mor-phinomanes. Bibliotheque medicale Charcot-Debove. 163 164 MANUAL OF PSYCHIATRY. can readily procure the poison; such are physicians, their wives, medical students, pharmacists, nurses, and laboratory attendants. As in the case of alcoholism, the character of the soil is here also an important factor. The less energetic and mentally stable the individual is the more likely he is to yield to the seductive influence of the poison. Thus we find that morphinomaniacs are often degenerates. (2) How does one become a morphinomaniacf — In many ways, but chiefly: (a) Through medication: many subjects receive their first injection for the relief of some painful affection, as hepatic colic, neuralgia, or tabes. (&) Through curiosity: this occurs especially among degenerates, idlers, individuals who are tired of all ordinary pleasures and are longing for new sensations, and whose unfortunate tendency is still farther stimu- lated by the example and proselytism of other mor- phinomaniacs. (c) Through the need of a cerebral sedative or of moral relief: this occurs in the overworked (soldiers in time of war or young people during difficult examinations) and in those who are driven by some misfortune or ill-luck to seek in morphine a consolation for their sorrows and disappointments. Doses. — The action of the poison becoming less effective in time, the doses necessarily increase more or less rapidly. The maximum doses taken daily by different patients vary greatly. One morphinomaniac, reported by Pichon, was in the habit of taking nine grams daily. Most patients limit themselves to smaller doses. Of the one hundred and twenty subjects com- CHRONIC INTOXICATION BY THE ALKALOIDS. 165 prised in the statistics of Piehon eighty-four took from 0.40 to 1.20 grams daily. The methods of morphinomaniacs. — The places usually selected for the injections are the arms, forearms, thighs, or legs; the next in frequency are the abdomen and the chest. Aery frequently these regions are covered with scars from abscesses caused by septic injections. These scars constitute, so to speak, the stigma of morphinomania and often enable the physician to establish the diagnosis in spite of repeated denials on the part of the patient. Many morphinomaniacs take their injections without regularity or precaution and at any opportunity ; others, in true epicurean fashion, select the moment and con- ditions when they can enjoy most profoundly their favorite pleasure. Some, again, have their hours regu- larly fixed, use only accurately prepared solutions of a certain strength, and take all antiseptic precautions; many take their daily quantity in divided doses ; others take a single large dose daily in order to obtain the most intense effect. SYMPTOMS AND EVOLUTION. According to Chambard four periods may be dis- tinguished in the career of a morphinomaniac, which succeed each other by imperceptible gradations. First period : initiation or euphoria. — It has been aptly called the honeymoon of the morphinomaniac. Under the influence of the morphine physical pains, if they exist, disappear or become abated, the organic functions become more active, and the mind lapses into a pleasant reverie; ideas form themselves without any effort and 166 MANUAL OF PSYCHIATRY combine "to form ingenious conceptions, elaborate resolutions, vast enterprises which, alas, are never likely to last through the day"; depressing thoughts disappear and life assumes a smiling aspect. Second period: hesitation. — Many subjects, conscious of their danger, make efforts to escape from it. They diminish the doses, reduce the number of injections, etc. Some even completely discontinue the use of the drug permanently or temporarily. The period of hesitation is not constantly present; many patients by reason of their ignorance or lack of determination pass directly from the first period to the third. Third period: morphinomania proper. — The poison has now impressed its stamp upon the organism and has established certain permanent symptoms. Moreover, its suppression gives rise to a series of characteristic phenomena, the symptoms of abstinence. (A) Permanent symptoms. — (a) Psychical phenom- ena. — These consist in a general weakening of the psychical activity, and are manifested in the intellectual sphere by a sluggishness of associations and an impair- ment of attention contrasting with an intact orienta- tion and a perfect lucidity, and b}' a retrograde amnesia of reproduction: the representations are in some way inhibited but not destroyed. In the emotional sphere there is indifference and atrophy of the moral sense. All the aspirations of the patient reduce themselves to a single idea, that of pro- curing morphine by any possible means: disregard for conventionalities, swindling, falsehoods, violence, all seem to him permissible. Many morphinomaniacs CHRONIC INTOXICATION BY THE ALKALOIDS. 167 obtain their morphine from the druggist on false pre- scriptions, others sell their very household articles to purchase morphine for the money. In the sphere of the reactions there is always a very marked aboulia. The patient is conscious of the ruin- ous results of his inactivity, but has not the power to overcome it. This symptom appears early and together with the indifference forms a characteristic feature of the mental state in morphinomania. (b) Physical symptoms. — The general nutrition always suffers: loss of flesh, pallor of the skin, etc. The circulatory apparatus shows a general atony. The cardiac impulse is weak; the peripheral circula- tion is sluggish; there are transient cedemas. The temperature is often subnormal. A case of mor- phine fever has, however, been reported (Levinstein). Motility: general muscular asthenia; a tendency to fatigue; tremors: "slow, regular oscillations resulting from a twisting movement of the limb upon itself." 1 Sensibility: slight hyperesthesia which is at times unilateral ; diminution of the acuteness. of vision, often dependent upon a "pallor of the optic disc, which may advance to atrophy." 2 The pupils are frequently myotic. The tendon reflexes are occasionally diminished. (B) Symptoms of abstinence. — When the hour for his injection has passed the morphinomaniac becomes rest- less, his expression becomes anxious, and his respirations accelerated. A state of anxiety soon appears, accom- panied by a very marked inhibition of all the psychic 1 Jouet. Quoted by Chambard, loc. cit. 2 Pichon. Le morphinisme, 1890. 168 MANUAL OP PSYCHIATRY. functions. The patient abandons his unfinished work or conversation and leaves, complaining that he is unable to bear the tortures of which he is a victim. At the same time there is the appearance of the pathogno- monic somatic symptoms: extreme pallor of the face, acceleration and weakening of the pulse, general pros- tration, cold sweats, and spells of yawning. If absti- nence continues the condition may become alarming: obstinate diarrhoea appears and collapse is threatened. No matter how grave the symptoms become an injec- tion of morphine always affords instantaneous relief. Occasionally the mental symptoms present all the features of a veritable acute psychosis: agitation^ anxiety, persecutory ideas, psycho-sensory disorders, excitement simulating that of mania; these may be associated with hysteriform or epileptiform attacks. Fourth period: cachexia. — The symptoms of the preceding period become more marked. The psychic disaggregation in some cases resembles true dementia. The craving for the drug is greater than ever. The loss of flesh reduces the patient almost to a skeleton; the stomach rejects the food and a permanent and intractable diarrhoea becomes established; the blood pressure becomes low, the cardiac impulse grows weaker and weaker, the pulse becomes small, thready, and irregular; the renal changes, which are frequent, give rise to albuminuria. Numerous complications are apt to appear, render- ing the prognosis still more serious: pulmonary tuberculosis, furunculosis, phlegmons hasten the fatal termination, which occurs at the end of the fourth period. CHRONIC INTOXICATION BY THE ALKALOIDS. 169 Associated intoxications. — The intoxicants, the abuse of which is often associated with morphine, are chiefly ether and cocaine. Cocainomania will be made the object of special study. Ether, absorbed from the respiratory tract or from the digestive passages, brings about a state of euphoria analogous to that produced by morphine. In certain cases there is a period of excitement which may reach the intensity of delirium and which is followed by comatose sleep. Treatment. — Its aim is the discontinuance of the morphine. This may be attained by three methods: the sudden method (Levinstein), the rapid method (Erlenmeyer), and the gradual method (the so-called French method). The suppression of morphine or demorphinization cannot be carried out outside of a sanitarium for the following two reasons: (1) because the patient should be, in case of threatened collapse, within immediate reach of medical aid; (2) because only a rigorous supervision can prevent the patient from procuring the drug clandestinely. The method of choice is rapid suppression. "It is a fact, recognized to-day by all physicians experienced in the treatment of morphinomania, that rapid sup- pression is the best method of treatment." x The period of demorphinization lasts from five to twelve days. The principle consists in diminishing the dose each day by one half of that administered on the pre- ceding day, and finally, on reaching a minute ration, completely suppressing the drug. It is in the latter 1 Sollier. La demorphinization. Presse medicale, April 23 and July 6, 1898. 170 MANUAL OF PSYCHIATRY. days of the suppression that the symptoms of abstinence appear with the greatest intensity. Patients who descend without much difficulty from one gram or more to several centigrams experience grave disturb- ances when they are deprived of this minute allowance. Adjuvant therapy. — The diet should be tonic and reconstructive. In the cases of marked cachexia it is advisable to improve the state of the general nutrition before the complete demorphinization. 1 The digestive tract and the heart demand special attention. Gastro-intestinal disorders may be prevented by the use of bicarbonate of soda (2-6 grams daily), and cardiac failure by heart stimulants, such as caffein, strophan- thus, and, if necessary, digitalis. A morphinomaniac cannot be considered recovered until a long time has elapsed after the suppression of the drug. The return to ordinary life is for him a critical moment; for this reason isolation in a sanitarium should be continued for several weeks after the last injec- tion. 2 This prolonged detention is further justifiable by the grave complications, notably fatal epileptiform attacks, which may occur long after complete demor- phinization. In spite of all these precautions permanent cures are the exception and relapses are the rule. 1 Joffroy. Traitement de la morphinomanie. Gaz. hebd. de Med. et de Chirurgie, 1899 and 1900. 2 [At least a full year's sojourn in a sanitarium under strict super- vision is necessary for the more or less successful prevention of relapses. See Kraepelin's Lectures on Clinical Psychiatry.] CHRONIC INTOXICATION BY THE ALKALOIDS. 171 § 2. COCAINOMANIA. It seems that cocainomania first appeared in 1878, when Bentley made the fatal suggestion of treating morphinomania by means of injections of cocaine. Like morphine, cocaine produces immediately after its absorption a peculiar state of euphoria characterized chiefly by a sense of vigor and energy. The craving becomes established after the first few injections, much sooner than in the case of morphine. I shall describe successively the habitual mental state of the cocainomaniac and the cocaine delirium. Habitual state. — Normal activity is replaced by in- dolence, and the affectivity by indifference. All the faculties are dulled. The memory is paralyzed, there being both anterograde amnesia by default of fixation and retrograde amnesia by default of reproduction. The mood is 'usually sad, gloomy, and pessimistic, and the will power is nil. This state of general enfeeblement is interrupted by sudden outbreaks of gaiety and feverish activity, which disappear very soon, leaving behind them an intensified psychasthenia. The sensory organs are the seat of hyperesthesia, so that even slight stimulation produces painful sensations. At intervals hallucinations appear, which constitute the germ of the true delirium. Conscious in the begin- ning, the hallucinations are later accepted by the sub- ject as real sensations. The general nutrition is poor. The skin assumes an earthy color; the weight is reduced; the process of digestion is sluggish and painful; and there is diarrhoea alternating with constipation. 172 MANUAL OF PSYCHIATRY. Cocaine delirium. — It is a delirium of a painful character associated with delusional interpretations; its main features consist in psycho-sensory disorders which, in spite of their extraordinary distinctness, are compatible with perfect lucidity. The illusions and hallucinations may affect all the senses, but especially vision, touch, and the muscular sense. Objects change their shapes and are constantly moving. A patient of Saury's x felt himself assailed by a swarm of bees which he could see and feel. Many cocainomaniacs feel worms creeping over their bodies or coming out of their flesh; they see them, seize them with their fingers, and crush them under their feet. Many also perceive imaginary movements: the ground shakes beneath them, their bed is upset, or the house they are in, swept by a flood, floats upon the waves. Hallucinations of hearing, taste, and smell, though not rare, occur less frequently than the preceding and present no special characteristics. Sometimes the delusions assume the form of morbid jealousy, as in systematized alcoholic delirium. The reactions of the patient are governed by the delusions and are often violent. The duration of the attack is brief, several weeks at the longest, and in some cases but a few days. I have seen a typical case of cocaine delirium terminate in forty-eight hours. The treatment consists in the suppression of the poison, which can in the great majority of cases be accom- plished by the sudden method without serious incon- venience. 1 Saury Coculnom