PART II — часть 5

The policy of the Association's committee on statistics in the differentiation of these conditions is shown by the following quotation on this subject from the last edition of the manual:—

"The relation which various mental disturbances bear to the disease pellagra is not yet settled. Cases of pellagra occurring during the course of a well established mental disease such as dementia praecox, manic-depressive insanity, senile dementia, etc., should not be included in this group. The mental disturbances which are apparently most intimately connected with pellagra are certain delirious or confused states (toxic-organ-like reactions) arising during the course of a severe pellagra. These are the cases which for the present should be placed in the group of psychoses with pellagra."

A study of recent statistics would tend to show that pellagra is not at this time a factor of importance in our institutions. In Massachusetts in 1919 the admission rate for this disease was .33 per cent. In New York state hospitals during a period of eight years it was only .03 per cent. In twenty-one hospitals in fourteen other states it amounted to only 1.28 per cent. This includes a number of institutions in the south. There were 263 cases (.37 per cent) in 70,987 first admissions to forty-eight hospitals in sixteen different states. The admissions reported from the southern institutions indicate that pellagrous psychoses are comparatively infrequent as a rule. During the year 1918 pellagra constituted 10.7 per cent of the admissions to the Columbia State Hospital. During the biennial period of 1917 and 1918 the admission rate at the Arkansas State Hospital for Nervous Diseases was 8.31 per cent. None were admitted to the Spring Grove State Hospital at Catonsville, Maryland. In 1919 the admission rate at the Western State Hospital at Staunton, Virginia, was 1.14 per cent, at the Central State Hospital, Petersburg, Virginia, 1.39 per cent, and at the Georgia State Sanitarium at Milledgeville, 2.49 per cent. One and sixty-one hundredths per cent of the admissions to the Louisiana State Hospital during 1920 were diagnosed as psychoses due to pellagra. Very few cases are reported in the northern institutions.

CHAPTER X

THE PSYCHOSES WITH OTHER SOMATIC DISEASES

Mental disturbances of various types associated with somatic conditions and not sufficiently characteristic or circumscribed in their symptomatology to constitute definite and separate psychoses have long been recognized. That delirium is a complicating factor in certain acute febrile diseases has been known for centuries. Aristotle called attention to the occurrence of hallucinations and illusions during the course of fevers. Hippocrates referred frequently, not only to excitements, but to delirium and phrenitis. The word "delirus" appears in several places in the works of Horace and many of the early authors apparently used this term as synonymous with both mania and melancholia. That was probably true of Sennert. Flemming in 1844 mentioned fever delirium, hallucinatory and delusional clouded states and an encephalitic form in addition to the various alcoholic types. Sydenham referred to the mental symptoms associated with malaria and Bright in his original "Reports" described other delirious conditions at some length. Sir Thomas Watson showed that the brain was uninvolved at autopsy in the acute rheumatic affections with apparent cerebral complications. Mental symptoms have, of course, been associated for hundreds of years with meningitic processes. Diabetic coma was also recognized long since. Griesinger is said by some to have been the first to call attention to the psychoses caused by the acute infections. Post febrile mental disturbances were, however, referred to by Sydenham, Baillarger, Westphal, Greenfield, Gubler and many others. Delasiauve very elaborately described the psychoses associated with typhoid fever in 1849. The mental disorders accompanying gout were discussed at considerable length by Sydenham and were referred to as early as 1699 by Philander Misaurus.

According to Bucknill and Tuke[261], Misaurus made the following very interesting suggestions in an article entitled "The Honour of the Gout": "It would be worth inquiry, whether the gout is not as effectual against madness; and we may reasonably believe that it is so, if upon examination, it should be found that there are no gouty people in Bedlam; and then for the recovery of these poor creatures to their wits again, it will not need much consideration, whether they ought not to be excused the hard blows which their barbarous keepers deal them, and the Therapeutic method of Purging, Bleeding, Cupping, Fluxing, Vomiting, Clystering, Juleps, Apozemes, Powders, Confections, Epithemes, Cataplasms, with which the more barbarous Doctors torment them, and instead of their learned Torture, indulged for a time only, a little intemperance as to wine, or women, or so; or the scholar's delight of feeding worthily, and sleeping heartily, whereby they might get the Gout, and then their madness were cured." Clouston described a very definite form of phthisical insanity. Van der Kolk made the surprising statement that phthisis and mania often alternated in regular cycles. Nasse classified the mental conditions associated with fevers as either resulting directly from the febrile disturbance, constituting a prolongation of the delirium after the temperature subsided, or developing during convalescence.

The German psychiatrists during the first part of the nineteenth century were divided into two quite separate groups. One of these insisted that all mental diseases were purely psychic in origin, and the other, that they were in all instances directly attributable to somatic disease processes. The former school was ably represented by Heinroth and Ideler and the latter by Jacobi, Nasse and Friedreich. This led to a controversy which lasted for many years. Heinroth's views were illustrated by his statement[262] that "Insanity is the loss of moral liberty. It never depends upon a physical cause; it is not a disease of the body but of the mind—a sin.... The man who has during his whole life before his eyes and in his heart the image of God, has no reason to fear that he will ever lose his reason.... Man possesses a certain moral power which cannot be conquered by any physical power, and which only falls under the weight of his own faults.... From wrong doing springs all misfortune, including the disorders of the mind." His principal work was a "Lehrbuch der Seelenkunde," published in Leipsic in 1818. The teachings of the psychic school were summarized by von Feuchtersleben[263] as follows:—"The mind is the immediate seat of the disease, the bodily suffering is secondary. Mental disorders may be clearly traced to their origin, Sin, Error, Passion. Diseases of the brain, on the contrary, and of all the organs, occur, even in their greatest intensity, without mental disturbance, as also the latter without the former. The psychical mode of cure is that which is properly efficient; the somatic remedies in reality act psychically; for instance through pain, diversion of the thoughts, stupefaction, terror. Pathological anatomy has not discovered any decided relation between disorganization of the brain and mental disorders." In 1836 Friedreich [264] in opposing Heinroth's views outlined thirteen reasons for believing that all psychic disorders were somatic in origin:—"1. Because the mind cannot become diseased; 2. because the greater part of the causes producing those conditions is somatic; 3. because in all mental disorders there are somatic symptoms in addition; 4. because they are too permanent for pure conditions of the mind; 5. because they are subject to cosmical and telluric states; 6. because their crises always take place in a material way; 7. because they are not infrequently removed by strong material influences; 8. because the somatic mode of cure alone has a direct sanatory effect, the psychical at most an indirect effect on the body; 9. because the occurrence of psychical indisposition on one side only, must arise from the duality of the brain; 10. because the return of reason before death occurs in cases not only of psychical, but likewise of somatic diseases, and may be physically accounted for; 11. because mental disorders correspond with the temperaments; 12. because it may be proved that there are psychical conditions which depend on organic causes, and are therefore very analogous to psychical disorders; 13. because chronic delirium (mania) can be no other than febrile." Absurd as such discussions may seem at this time, they are no worse than the theological debates of that day. As a matter of fact, they were no more futile than the efforts still being made to classify the various psychoses on some one common ground, for any other than purely statistical purposes.

Kraepelin[265] divides the psychoses due to infection into febrile delirium, infection delirium, acute confusional states (amentia) and exhaustions. The result of the infectious process, as he says, may be merely to precipitate a manic-depressive psychosis, or an attack of dementia praecox, general paresis or delirium tremens. It may also be manifested in the form of a neuritis, myelitis, encephalitis, or a meningitis. Bonhöffer in 1910 described several forms of "symptomatic psychoses" due to infections and divided them into three main groups: deliria, confusions and mental enfeeblements. He also referred to epileptiform excitements, dream states, hallucinoses, manic types and amentias either hallucinatory, catatonic or incoherent in character.

Kraepelin speaks of several definite stages or forms of febrile delirium. In the mildest of these there is a feeling of discomfort with a sensation of fulness in the head and a marked sensitiveness to external impressions. In the second stage a suggestion of clouding becomes apparent and perception is distorted by hallucinations and illusions. There is an increased activity of the mental processes and consciousness soon assumes a dreamlike form. Hallucinations and illusions are mixed with realities. The restlessness increases and excitements or depressive moods may precede the appearance of the third stage. In this there is a more pronounced disturbance of consciousness with disorientation, confusion, flight of ideas, and variable emotional reactions, sometimes with actual manic manifestations. Evidences of stuporous tendencies may appear at times. In the fourth stage a state of weakness develops, with picking at the bed clothes, tremulous movements and a senseless muttering of words and syllables. This terminates in complete coma. In smallpox, scarlet fever, erysipelas, articular rheumatism and pneumonia there are often sudden confused excited states, while in typhoid fever stuporous delirium is the rule. Hendriks found the mental symptoms in typhoid greater during convalescence and not closely related to the febrile reaction. He describes a marked disturbance of attention with little involvement of apprehension or comprehension, but marked loss of mental capacity and sometimes a tendency to confabulation. Visual hallucinations and loss of sleep are common symptoms. Often there is restlessness, talkativeness, indifference, carelessness and disturbances of volition. In articular rheumatism and scarlet fever, according to Kraepelin, delirium sometimes develops with sudden rise of temperature. Restlessness, talking in the sleep, volubility or dulness precede an unusually violent delirium, sometimes terminating in stupor and death. The basis of these conditions in all cases is the toxic infection causing the fever, changes in metabolism, circulatory disturbances and an involvement of various organs, particularly the brain. A rapid and considerable rise of temperature usually causes delirium in typhoid, smallpox and erysipelas while it has no such effect usually in tuberculosis. This disturbance is a direct result of the influence of the toxins on the cortex. Alcoholism constitutes another well-known and common cause. In seventy per cent of the cases the duration was less than one week and the delirium disappeared with the fall in temperature. Some cases terminate in infection delirium or they may precipitate genuine attacks of manic-depressive insanity, dementia praecox or general paresis.

The so-called acute alteration of Nissl was a very common change found in the cortical cells at autopsy. This very generally involved the entire cortex. Kraepelin describes another characteristic alteration observed in cases of typhoid delirium. The Nissl bodies are clumped together in the periphery, and are deeply stained, the processes also being unusually dark. Some cells show a shrunken nucleus with swollen, lightly stained bodies. Around these neurones there are usually large accumulations of elongated glia cells.

In the infection delirium, so called, the mental disturbance develops in a case where there is no hyperpyrexia or where at least there is no relation between the psychosis and the temperature. A restless excitement ushers in the attack. Pressure in the head, mental dulness, depressed or sometimes cheerful moods, uneasiness, disturbed sleep and anxious dreams are common symptoms. Later a disturbance of consciousness appears and a special type known as "initial delirium" may develop. This is a common occurrence in typhoid fever.

Aschaffenburg described two forms of initial delirium. The first is a restless condition of clouding with hallucinations and delusions. The second form, which may develop from the first, shows active mental excitement. Mild in its onset, a confusional delirious state soon develops with flight of ideas, hallucinations, delusions, and marked anxiety. An initial delirium of this type often occurs in smallpox. This assumes a particularly severe form with a tendency to suicide and violence, strongly resembling epileptic dream states. Seizures and epileptiform convulsions may occur. The delirium usually develops from the third to the fifth day of the disease and mental enfeeblement sometimes follows. The attack usually lasts from several days to a week. It may continue as a fever delirium. About forty or fifty per cent die. Nissl in one case found a marked congestion of the vessels of the cortex, with an increase in the number of leucocytes, and a widespread destruction of the neurones. The cell bodies were swollen and the chromatin lumps destroyed. Karyokinetic changes were noted in the glia cells.

More or less similar delirious states occur in the course of intermittent malarial fevers. These usually take the form of a marked anxious excitement, often with stupor or a tendency to violence. The attacks begin suddenly, last only a few hours and end in sleep. Convulsions are frequently observed. These conditions occur in the quotidian or tertian types but rarely in the quartan. The delirium precedes a febrile disturbance or may take its place. It is apparently due to an accumulation of plasmodia in the cerebral vessels. In influenza, restlessness, confusion, anxious excitement or hallucinatory deliria may be associated with a low temperature. Polyneuritic manifestations have also been observed. The disturbance is undoubtedly caused by the influenza bacillus or the action of its toxins on the cortex. Abscesses are found in some instances. Deliria with phthisis are rare unless there is a tubercular meningitis. In the septic infections, conditions with marked clouding are often observed, and are to be attributed to embolism, metastases, etc. Muscular weakness, aphasia, perseveration and convulsions may be present in these cases. Infection delirium also occurs in chorea. This takes the form of a clouded dreamlike state with confusion of thought at times, hallucinations, delusions, and emotional excitement accompanied by characteristic choreiform movements. Apprehension, as a rule, is unimpaired, but attention is disturbed and the patients are forgetful and distractible. They do not have a clear grasp on their surroundings. Occasional hallucinations appear. The mood is anxious, excited, fearful or irritable, sometimes with outbursts of anger or threats of suicide. The choreiform attacks are aggravated and speech is affected. The reflexes are decreased and muscular weakness develops. The pupils are dilated and sleep is interfered with to a marked degree. This excitement lasts for a short time only, but often recurs. In nine per cent of the cases (Kleist) death results from heart failure, septic infection or other intercurrent diseases. Wassermann and Westphal demonstrated streptococci in the brain in several cases of chorea. Others have reported staphylococci in the blood. Choreic delirium is usually associated with endocarditis or rheumatic infections, and occurs in the acute type but not in the Huntington variety of the disease.

Delirious excitements, according to Kraepelin, also occur in acute cerebrospinal inflammatory processes and may be due to furunculosis or caused by infections from the mouth or the intestinal tract. There is nothing particularly characteristic in such conditions aside from their severity. They have been collectively described under the designation of "acute delirium." Their differentiation depends entirely on the demonstration of the source of infection. The anatomical basis for these disturbances is always found in the cerebral cortex. The pia is infiltrated with lymphocytes and plasma cells and leucocytes are found in the perivascular spaces. There is also a proliferation of the glia. The "grave" alteration of Nissl is often demonstrable. After the infectious process passes its maximum intensity and the delirium disappears, "residual" delusions may remain with a clear sensorium. These may last for several days or even weeks. They frequently follow typhoid fever. Occasionally hallucinations of sight and hearing persist in the same way.

"Collapse delirium" was first described by Hermann Weber in 1866. It takes the form of a stuporous state with confusion of thought, dreamy hallucinations, flight of ideas, an unstable emotional condition and an active motor excitement. The onset is usually sudden, following a period of sleeplessness and restlessness. Disorientation occurs early and consciousness is markedly clouded. Phantastic hallucinations and illusions are frequent. Excitement and confusion are also prominent symptoms. Flight of ideas is common and the patient often sings or expresses himself exclusively in verse or rhymes. Senseless and rapidly changing delusions are noted. The mood is elated, erotic, anxious or irritable, with outbursts of anger. Motor excitement is conspicuous and there is no sleep. Usually food is refused and nutrition disturbed with a great reduction of bodily weight. This condition is of short duration, usually not more than a few days, often terminating in sleep in favorable cases. Only a confused recollection of events remains on recovery. Collapse delirium, according to Kraepelin, is purely an infectious process and often occurs in pneumonia, erysipelas and influenza, following the subsidence of the active symptoms of the disease. It occasionally complicates articular rheumatism and scarlet fever. The characteristic features in erysipelas are hallucinations and delusions of a delirious type, while clouded states, confusional excitements and flight of ideas are more common after pneumonia. The symptoms usually develop after the temperature falls and other evidences of weakness are present. Kraepelin, however, recognizes infection as the only cause at this time, although he previously described these as exhaustive conditions.

Acute confusional states or amentia were described by Meynert in 1881. These are characterized by a clouding of consciousness with multiform manifestations of excitement both sensory and motor. Amentia is one of the sequelae of infectious diseases. It takes the form of a subacute development of a dreamlike confusion with hallucinations, illusions and motor excitement lasting usually for several months. It is very closely related to collapse delirium and the hallucinatory insanity of Hoche, Fürstner and others. The early symptoms are sleeplessness and unrest. The patients become anxious, forgetful, develop a fear of death, and cannot control their thoughts, complaining of dulness and confusion of mind. A difficult comprehension of external impressions develops. They may be attentive and seriously troubled at not being able properly to grasp their surroundings. A decided uncertainty and restlessness results. Everything seems changed or false. There is at first a feeling of inadequacy and a profound disturbance of thought which develops into a well defined confusional condition. A dreamlike state follows, sometimes with a tendency to fabrications. Rhymes, phrases and words may be repeated frequently. There is a tendency towards distractibility and flight of ideas with vague thoughts of persecution. Hallucinations sometimes become apparent, and illusions appear. The mood is usually one of irritable anxiety, suspicion and mistrust, seldom with complete dulness. Occasional outbursts of anger take place. A restless behavior is noted as a rule. Sometimes suicidal tendencies occur and mild stuporous states follow.

In another group of cases depression is an especially prominent feature as occasionally happens after typhoid fever; or states of excitement may exist with a flight of ideas and delusions of grandeur. Before the febrile disturbance has disappeared signs of restlessness are noted. Orientation is soon lost, apprehension is disturbed, the patient becomes distractible and begins to show hallucinations. Ideas of grandeur develop and fabrications are conspicuous and extravagant. The mood is angry and irritable, sometimes cheerful or elated, but very changeable. Restlessness, volubility, flight of ideas, senseless rhyming, confused writing and tendencies to sing, etc., soon appear. The sleep is very much disturbed. Very little nourishment is taken or it is refused entirely. Bodily weight is greatly reduced. The reflexes are usually increased, the pulse slow and the temperature subnormal. The duration of the disease is usually not more than from two to six months. Amentia usually follows typhoid, articular rheumatism, smallpox and cholera, and occasionally occurs after pneumonia. Symptoms invariably develop after the fever has subsided. After typhoid the characteristic features are excitement with hallucinations, delusions and variable moods; after articular rheumatism, disturbance of apprehension, restlessness, depression or even stupor; and after phthisis, hallucinations with preservation of consciousness and slight confusion.

Light forms of the infectious exhaustions, according to Kraepelin, may appear after convalescence from the more severe illnesses. The patient does not make a good recovery, is exhausted, cannot think clearly, tires easily and is not able to read or write letters. Mental activity is weakened and the patient remains in bed, apathetic and indifferent. Consciousness, orientation and perception are undisturbed, although hallucinations may appear when the eyes are closed or noises in the ears may be noticed. The mood is gloomy, hopeless, and sometimes irritable, with sudden attacks of anxiety at night. The patient becomes suspicious and has fears of death or poisoning. Hypochondriacal feelings with self-accusation may develop. Food may be refused and suicidal attempts occur. Some cases are reserved and quiet, even stuporous, expressing only a few delusional ideas at times. Sleep and appetite are affected and weight lost as a consequence. These lighter forms usually follow influenza, articular rheumatism, whooping cough, tuberculosis or chorea. The duration is ordinarily brief—a few weeks or months, followed by recovery. In some instances the disease may progress to a complete enfeeblement of the mental processes.

The exhaustive conditions in a large group of more severe cases are ushered in by a delirium or confusional state with a depressed mood. There is first a slight anxiety. Self-accusation and persecutory ideas appear early. Hallucinations of hearing and vision develop. The patients soon become clouded, inattentive, show difficulty of thought and loss of memory, with mental dulness. All grasp upon their surroundings is lost, they fail to recognize members of the family, and answer questions unintelligently. They have no appreciation of their condition and no memory for events. The mood is indifferent, apathetic or whining. It may be irritable, quarrelsome or violent. Usually they lie in bed and are entirely apathetic. Sometimes they show automatic movements and have to be fed. The conversation is often incoherent and meaningless. They are inclined to be emotional. Sleep is usually interfered with and they are restless at night. The appetite is lost. Occasionally evidences of brain lesions appear with paralyses, speech disturbance or epileptiform seizures. The duration is usually a matter of a number of months. At autopsy grave cell alterations and glia reactions are common. Rod cells are also found. Endothelial proliferation is frequently observed in the vessel walls. Some cases terminate in a chronic condition which may improve somewhat in time. There may be a persistent emotional and mental enfeeblement with indifference, loss of memory, lack of judgment and impairment of will. These "acute dementias" represent the terminal stages of cortical infectious processes. They have been observed after typhoid, rheumatism, erysipelas, cholera, smallpox and malaria. Usually after tubercular peritonitis or articular rheumatism there is a simple mental enfeeblement, while erysipelas is usually accompanied by mild excitements and an elated mood. The typhoid cases usually showed irritability, with outbursts of anger and confusional states with hallucinations and delusions. They occasionally terminate in more chronic conditions with permanent deterioration.

After typhoid, influenza and septic infections, Korsakow's "cerebropathica psychica toxaemica" sometimes occurs. This is the polyneuritic psychosis similar to that caused by alcohol. There is, however, a delirium or stupor at the same time.

The post-rheumatic psychoses have been studied exhaustively by Knauer.[266] Stuporous attacks were found in ninety-three per cent of his cases, following acute infections. He describes four groups showing psychotic manifestations:—

1. Anxious delirious excitements followed by stupor.
2. Excitements alternating with stupor.
3. Stuporous depression throughout.
4. Amentia-like excitements throughout.

The essential feature of Knauer's study was an analysis of post-rheumatic stupors. He describes these as clouded or dream states "not different from physiological sleep and the ordinary artificial narcoses." In them he sees a disturbance of apprehension, an interference with intellectual processes, a retention defect, and a loss of the power of attention. Catalepsy was found to be present in the majority of his cases. The loss of affect was described as being more complete than in manic-depressive psychoses. He speaks of the mood as sad, depressed, anxious, but above all, changeable.

Generally speaking this group of psychoses due to somatic disease is one which requires further study. We have comparatively little statistical information on the subject as yet. The differentiation of these conditions as outlined in the Association's statistical manual is as follows:—

"Under this heading are brought together those mental disorders which appear to depend directly upon some physical disturbance or somatic disease not already provided for in the foregoing groups.

"In the types designated below under (a) to (e) inclusive, we have essentially deliria or states of confusion arising during the course of an infectious disease or in association with a condition of exhaustion or a toxaemia. The mental disturbance is apparently the result of interference with brain nutrition or the unfavorable action of certain deleterious substances, poisons or toxins, on the central nervous system. The clinical pictures met with are extremely varied. The delirium may be marked by severe motor excitement and incoherence of utterance, or by multiform hallucinations with deep confusion or a dazed, bewildered condition; epileptiform attacks, catatonic-like symptoms, stupor, etc., may occur. In classifying these psychoses a difficult problem arises in many cases if attempts are made to distinguish between infection and exhaustion as etiological factors. For statistical reports the following differentiations should be made:

"Under (a) 'Delirium with infectious diseases' place the initial deliria which develop during the prodromal or incubation period or before the febrile stage as in some cases of typhoid, small-pox, malaria, etc.; the febrile deliria which seem to bear a definite relation to the rise in temperature; the post-febrile deliria of the period of defervescence including the so-called 'collapse delirium.'

"Under (b) 'Post-infectious psychoses' are to be grouped deliria, the mild forms of mental confusion, or the depressive, irritable, suspicious reactions which occur during the period of convalescence from infectious diseases. Physical asthenia and prostration are undoubtedly important factors in these conditions and differentiation from 'exhaustion deliria' must depend chiefly on the history and obvious close relationship to the preceding infectious disease. (Some cases which fail to recover show a peculiar mental enfeeblement.) In this group should be classed the 'cerebropathica psychica toxaemica' or the non-alcoholic polyneuritic psychoses following an infectious disease as typhoid, influenza, septicaemia, etc.

"Under (c) 'Exhaustion deliria' are to be classed psychoses in which physical exhaustion, not associated with or the result of an infectious disease, is the chief precipitating cause of the mental disorder, e.g., hemorrhage, severe physical over-exertion, deprivation of food, prolonged insomnia, debility from wasting disease, etc.

"Of the psychoses which occur with diseases of the ductless glands, the best known are the thyroigenous mental disorders. Disturbance of the pituitary or of the adrenal function is often associated with mental symptoms.

"According to the etiology and symptoms the following types should therefore be specified under 'Psychoses with Other Somatic Diseases':

"(a) Delirium with infectious disease (specify)
"(b) Post-infectious psychosis (specify)
"(c) Exhaustion delirium
"(d) Delirium of unknown origin
"(e) Cardio-renal disease
"(f) Diseases of the ductless glands (specify)
"(g) Other diseases or conditions (to be specified)."

A study of 480 cases of psychoses with other somatic diseases reported from the New York state hospitals during 1918 and 1919 shows the following types represented:—

An analysis of 140 cases from the Massachusetts state hospitals in 1919 shows the following:—

Three hundred and sixteen cases from hospitals in nineteen other states were reported as follows:—

We have, thus, a total of 936 cases distributed as follows:—Delirium with infectious diseases, 19.76 per cent; post-infectious psychoses, 16.77; exhaustion delirium, 20.83; delirium of unknown origin, 8.01; cardio-renal diseases, 13.88; diseases of the ductless glands, 3.84; and other conditions, 16.88 per cent. Four and one hundredth per cent of the first admissions in Massachusetts, 3.45 per cent of the New York admissions, and 2.07 per cent of admissions to twenty-one other institutions during the same period of time were cases of psychoses due to other somatic diseases. They constituted 2.81 per cent of 34,935 admissions to all of the institutions above noted.

CHAPTER XI

THE MANIC-DEPRESSIVE PSYCHOSES

The manic-depressive psychoses as first described by Kraepelin are of comparatively recent origin. The history of the clinical entities included in this new grouping, however, may be easily traced back to the earliest days of psychiatry. Although these terms were not used perhaps as they came to be later, mania and melancholia were, as has already been shown, known in the Hippocratic era, over four hundred years before the time of Christ. They were referred to again in the works of Aretaeus in the first century A. D. and were recognized by Celsus, Caelius Aurelianus and Galen. Daniel Sennert[267] of Wittenberg (1572-1637) defined melancholia as a "delirium or deprival of imagination and reason, without fever, with fear and sadness, arising from dark and melancholy animal spirits, and occasioning corresponding phantoms." Mania he described as a "delirium or deprival of imagination and reason without fear, but, on the contrary, with audacity, temerity, anger, and ferocity, without fever, arising from a fervent and fiery disposition."

Sydenham[268] recommended bleeding, followed by purgation, as the treatment indicated for mania:—"Thus the humours, which in mania would invade the citadel of the brain, are gradually drawn off towards the lower parts, a fresh bias being given to them."

Thomas Willis [269] made some very significant references to the relation existing between mania and melancholia, in the seventeenth century:—"After melancholia we have to treat of mania, which has so many relations to the former, that the two disorders often follow each other, the former changing into the latter, and inversely. The melancholic diathesis, indeed, carried to its highest degree, causes frenzy, and frenzy subsiding changes frequently into melancholia (atrabiliar diathesis). These two disorders, like fire and smoke, often mask and replace each other, and if we may say that in melancholia the brain and the animal spirit are obscured by smoke and black darkness, mania may be compared to a great fire destined to disperse and to illuminate it." Morgagni,[270] "the father of pathology," also saw a close relation between these two conditions as is shown by the following quotation from his "De Sedibus et Causis Morborum;" etc., in 1761. "Melancholia," he says, "is so nearly allied to mania, that the diseases frequently alternate, and pass into one another; so that you frequently see physicians in doubt whether they should call a patient a melancholiac or a maniac, taciturnity and fear alternating with audacity in the same patient; on which account, when I have asked under what kind of delirium the insane persons have laboured whose heads I was about to dissect, I have had the more patience in receiving answers which were frequently ambiguous and sometimes antagonistic to each other, yet, which were, perhaps, true in the long course of the insanity." Flemming[271] in 1844 described a "dysthymia atra" (melancholia), a "dysthymia candida" (cheerful dysthymia) or "melancholia hilaris" characterized by elation with playfulness and a "tendency to see everything in the most pleasant and cheerful light" as well as a "dysthymia mutabilis," an alternating variety involving both of the above forms. He also spoke of a "dysthymia sparsa" (apathica) or "melancholia attonita," and a "vesania maniaca" or mania which he divided into the acute, delirious, alcoholic, affective, and puerperal types, together with an "occult amentia" embracing all of these forms. Griesinger[272] in 1845 called attention to the fact that "the transition of melancholia into mania, and the alternation of these two forms, are very common." In 1851 Falret, senior, first described circular insanity in his lectures at the Salpêtrière, quoted by Tuke[273] as follows:—"We have also to mention another case of intermittence observed between the periods of remission and excitement in the forme circulaire des maladies mentales." "It is a special form which we call 'circular' and which consists, not as has been frequently said, in a change of mania into melancholia separated by a more or less prolonged lucid interval, but in the change from maniacal excitement—simple overactivity of all the faculties—into mental torpor."

In 1854 at the Academy of Medicine in Paris Falret presented his "Mémoire sur la folie circulaire, forme de maladie mentale caractérisée par la reproduction successive et régulière de l'état maniaque, de l'état mélancolique, et d'un intervalle lucide plus ou moins prolongé." In the same year Baillarger described his "Folie à double forme," summarized by him in a Bulletin of the Academy of Medicine as follows:—

"(1) Besides monomania, melancholia, and mania, there exists a special form of insanity characterized by two regular periods, one of depression, the other of excitement.

(2) This form of insanity: (1) presents itself in isolated attacks; (2) reproduces itself in intermissions; (3) the attacks may follow each other without interruption.

(3) The duration of the attacks varies from two days to one year.

(4) When the attacks are short, the transition from the first to the second period takes place suddenly, and generally during sleep. It takes place slowly and gradually when the attacks are prolonged.

(5) In the latter case, the patients seem to enter into a state of convalescence at the end of the first period, but this return to health is incomplete; after a fortnight, a month, six weeks or more, the second period breaks out."

This was described as "Folie à double phase" by Bellod, "Folie à formes alternés" by Delaye, "Délire à formes alternés" by Legrand du Saulle, "Die cyclische Psychose" by Ludwig Kirn and "Das circuläre Irresein" by Krafft-Ebing.

At a meeting of the American Association in 1886 the classification of the British Medico-Psychological Association was adopted with the omission of moral insanity and the addition of toxic insanity. This included the following types of mania:—Recent, chronic, recurrent, à potu, puerperal and senile, and classified melancholia as recent, chronic, recurrent, puerperal and senile. In his "Clinical Lectures on Mental Disease" Clouston in 1898 described eight varieties of melancholia and six of mania, not including alternating forms. Kahlbaum in 1882, reverting apparently to the phraseology of Flemming, spoke of dysthymia, hyperthymia and mixed or circular forms—cyclothymia. Many of the conditions afterwards classified under dementia praecox he described as "vesania typica."

It will be observed that, based somewhat on the conceptions of Griesinger, states of mental excitement were generally characterized as mania and all depressions as melancholia. As has been shown, the view that there was some definite relation between these two conditions had been gaining ground for many years and culminated in the "circular insanity" concept. In the meanwhile over fifty varieties of mania and thirty forms of melancholia were described by various authors. Aside from an emotional exaltation and increased psychomotor activity, few definite characteristics were insisted upon in a consideration of mania. There was almost invariably a disturbance of sleep but always with a sense of well-being and no feeling of exhaustion. The milder type of the disease was often referred to as "hypomania." In the more severe forms varying grades of violence developed. There was at times a clouding of the sensorium, a temporary appearance of hallucinations of sight and hearing, delusions of a persecutory or grandiose nature and incoherence of speech. Impulsive acts occasionally were noted during the height of the excitement. These attacks were frequently preceded by brief periods of depression. Many cases made rather early recoveries—others, however, were spoken of as having reached a chronic stage. Many terminated in dementia. These very often showed stereotypies, verbigeration, impulsive excitements, mannerisms and other symptoms now held to be characteristic of dementia praecox. Melancholia was looked upon as including all emotional depressions with hallucinations and delusions as the prominent symptoms. The mental state was essentially one of sadness but with fear, agitation and anxiety appearing at times. There was, however, no attempt at any differentiation between psychomotor retardation with genuine depression and apathetic states or actual mental dulness. Mutism and resistiveness were common. A refusal of food was rather to be expected. Stuporous states with muscular rigidity frequently occurred. Various physical changes were described. Cyanosis of the extremities was emphasized, with loss of weight and a lowered temperature. Many of the cases were untidy in their habits. Brief initial attacks of excitement were mentioned as usually ushering in the disease. These depressions recovered, became chronic, lasting for years, or terminated in a partial or complete dementia. These were in substance the views of practically all of the earlier writers on insanity.

Sankey[274] in 1884 included in his idiopathic psychoses due to pathological conditions, general paresis and "ordinary insanity." "This is the disease which in its course presents such varying phenomena, and has thus given occasion for multiplying the names." Prominent in this group were the various forms of mania and melancholia and it undoubtedly included dementia praecox. "Like other diseases it may be artificially divided into separate stages, and this is useful for facilitating description, but such artificial divisions must not be looked upon as different species of disease." ... "Thus, a case in the primary attack commences by symptoms of melancholy; these may, when successfully treated, pass off, and the patient recover, or the melancholic stage may be aggravated, and the patient die in this stage;—the disease may exhibit symptoms of violence and become acutely maniacal. There is no ground on this account to say, that the patient has a new disease, any more than the appearance of an eruption in an eruptive disease would be the inauguration of a different kind of malady." Although obviously he had no idea as to the fundamental differences between manic-depressive insanity and dementia praecox, he unquestionably was one of the first to emphasize the fact that mania and melancholia were often definite stages of one disease process.

In 1896 Kraepelin described melancholia as essentially an involutional condition. Under the heading of periodic constitutional disorders he included mania, circular and depressive forms, the mania, melancholia, and circular insanity of other writers. Schüle[275] in 1886 described circular, periodical and alternating psychoses. In 1894 Ziehen[276] included in his classification under the heading of combined psychoses a "melancholisch-maniakalisches" form in addition to mania and melancholia, which he spoke of as affective psychoses.

It was not until 1899 that these conditions were clearly differentiated by Kraepelin[277] and the purely emotional and recoverable forms separated clinically from the deteriorative processes which he has associated with dementia praecox. The former he described as manic-depressive psychoses, which included mania, melancholia and a majority of the circular and alternating types previously described. This delimitation had a prognostic as well as an important symptomatic significance. The emotional excitements were characterized by an increased psychomotor activity, with a flight of ideas and distractibility, usually associated with a clear sensorium. Graver forms were, however, recognized, with a clouding of consciousness, and disorientation, occasionally terminating in stupor. Hallucinations and delusions when present were not prominent symptoms. The depressions were characterized by an emotional disturbance in the form of sadness with difficulty in thinking, associated with marked retardation in speech and a motor inhibition. More advanced stages showed clouding, disorientation, stuporous phases and hallucinations. He also recognized alternating or circular as well as mixed types. The prognostic importance of this clinical grouping was the tendency towards a complete recovery from the individual attack, with, however, an extreme probability later of a recurrence, the subsequent attacks assuming either form of the disease. As a rule Kraepelin found that the unfavorable types formerly included in the manias and melancholiac, together with the hebephrenia and katatonia of his fifth edition, presented the definite characteristics of the disease which he described as dementia praecox. His views have been modified from time to time. For instance, he at one time excluded the involutional and anxiety psychoses from his manic-depressive group. Later these were included. In his last edition he has described depressed and agitated forms of dementia praecox, which would strongly suggest that his lines of demarcation were not so clear as he believed them to be in 1899. Of the manic-depressive psychoses he says, "Manic depressive insanity as described in this chapter includes on the one hand the entire domain of the so-called periodic and circular insanities, on the other, simple mania, the larger part of the disease process described as melancholia and also a not inconsiderable number of cases of Amentia. Finally we include certain mild morbid emotional states, some periodical, some continuous, which heretofore have been looked upon either as introductory to more severe disturbances or as belonging, without being sharply circumscribed, to the domain of individual makeup. As years go by I have become more and more convinced that these all represent manifestations of one disease process." The following classification of manic-depressive psychoses was shown in Kraepelin's last edition (1913):—

Manic types:

Hypomania, Acute mania, Delusional and Delirious forms.

Depressive types:

Melancholia simplex, Melancholia gravis, Stupor, Paranoid, Phantastic and Delirious forms.

Mixed types:

Depressive mania.
Excited depressions.
Mania with poverty of thought.
Manic stupor.
Depression with flight of ideas.
Retarded mania.

The mixed and atypical forms are of special importance, as they occupy the middle ground between the classical types of manic-depressive insanity and dementia praecox. It is here that difficulties arise and errors in diagnosis are made. They have never received sufficient attention until recently. In practice many of these have undoubtedly been classed with the dementia praecox group. The first of these as described by Kraepelin is depressive or anxious mania—characterized by a depressive mood with anxiety and excitement and, at the same time, a flight of ideas. The patients are distractible, observant of everything in their surroundings, and complain that thoughts obtrude themselves upon them. Some have a mania for scribbling. Often there are delusions of persecution, sin, and hypochondriacal ideas. The mood is one of anxiety or despair. Impulsive acts are occasionally observed. They are inclined to weep, wring their hands, pull out their hair and throw themselves on the ground.

Instead of a flight of ideas there may be poverty of thought and retardation with excitement—an "excited depression." The patients may be very wordy and monotonous in expression but are entirely clear as to their surroundings. The mood is anxious and tearful, often with delusions. There is a considerable excitement, but not of such a stormy character as in the depressive or anxious mania.

Mania with poverty of thought, an "unproductive" form, shows a more cheerful mood but without a flight of ideas. This form Kraepelin speaks of as a common one. Speech is monotonous and expressionless. The patients present almost an appearance of feeblemindedness, although exceedingly variable and changeable. The mood is cheerful and sometimes irritable. The excitement is shown by jumping around, making faces, etc., but without any occupational activity. This alternates with periods of quiet when but little is said. They show no desire to occupy themselves in anything useful. Sudden outbursts of violence often occur.

Stuporous, almost cataleptic forms with occasional delusions of a hypochondriacal type, fairly well oriented and with a clear sensorium, are spoken of as "manic stupor." This is interrupted by excitement and violence, with laughter, witty remarks and even eroticism. They often have a clear memory of all occurrences. This stuporous type may appear suddenly in an ordinary manic attack, or take place between excitements and depressions.

In the course of an ordinary depression a flight of ideas may also replace the usual retardation—"depression with flight of ideas." The delusions are interspersed with cheerful thoughts and the patients show certain activities and an interest in their surroundings, although still depressed and hopeless. When they begin to talk they complain of an inability to control their thoughts. There is an inhibition of speech but not of thought. They may be quite prolific in writing, and may show a characteristic flight of ideas. This condition often merges into genuine excitement.

Kraepelin also speaks of an inhibited or "retarded mania," showing a cheerful mood with flight of ideas and psychomotor retardation. These eases are excited, distractible, inclined to witticisms with "klang associations," but lie quietly in bed. He believes that there is an inner tension manifesting itself at times in acts of violence. Kraepelin also speaks of various other mixtures of depression, anxiety and excitement. Specht has described an "irascible mania" (Zorntobsucht) and Stransky a bashful mania (verschämte Manie). Dreyfus has described a partial inhibition or retardation (partiellen Hemmung). Hecker is responsible for a "grumbling" or faultfinding variety of mania (nörgelnden Formen der Manie). In any event, Kraepelin's conceptions constitute a distinct advance and have materially clarified a much involved confusion of entities which seem to warrant complete differentiation. His views have, of course, not been universally accepted. The English school of psychiatrists has been slow in expressing its approval of his theories. No textbook of late years has appeared, however, in this country that has failed to recognize the manic-depressive psychoses practically as Kraepelin originally described them.

The psychological mechanisms of manic-depressive insanity have been studied exhaustively by Karl Abraham and other psychoanalysts. He looks upon retardation as a symbol of death and interprets it as a defensive reaction, the patient taking refuge in a retarded state to avoid contact with the outer world. The ideas of poverty associated with depressions he considered as symbolic of an inability to love and occurring in individuals who have not obtained sexual gratification in a normal way. When repression is no longer possible mania ensues and the patient enters upon a new existence, all instinctive inhibition being lost. The flight of ideas he looks upon as a reestablishment of infantilism. He suggests these views, however, as tentative. The delusions of the manic-depressive psychoses have been interpreted as an expression of repressed complexes. White[278] would explain these mechanisms as follows:—"Manic-depressive psychosis is the type of extroversion reaction. That is, the patients instead of turning within themselves (introversion) try to escape their difficulties (conflict) by a 'flight into reality.' This flight into reality is the manic phase of the psychosis with its flight of ideas, distractibility and increased psychomotor activity during which the patient seems to be at the mercy almost of his environment having his attention diverted by every passing stimulus. The great activity can be understood as a defense mechanism. The patient appears, by his constant activity to be covering every possible avenue of approach which might by any possibility touch his sore point (complex) and so he rushes wildly from this possible source of danger to that meanwhile keeping up a stream of diverting activities. He is at once running away from his conflict—into reality—and trying to adequately defend every possible approach.... This method I have described as a 'flight into reality' which is the characteristic of the manic phase, while the failure to deal adequately with the difficulty is manifested by the depression of the depressive phase. In the depression the defenses have broken down and the patient is overwhelmed by a sense of his moral turpitude (self-accusatory delusions). This sense of being sinful is the conscious appreciation of tendencies which should have been left behind to become a part of the historical past (the unconscious) in the course of the development of the psyche but which still demand expression.... The benign character of the manic-depressive group of psychoses is explained because of their extroverted mechanism. Reality is the normal direction for the libido and because the direction is normal they more readily result in recovery."

The American Psychiatric Association, in its manual designed for the assistance of hospitals for mental diseases in the compilation of statistical data, makes the following suggestions as to the delimitation of the manic-depressive psychoses:—

"This group comprises the essentially benign affective psychoses, mental disorders which fundamentally are marked by emotional oscillations and a tendency to recurrence. Various psychotic trends, delusions, illusions and hallucinations, clouded states, stupor, etc., may be added. To be distinguished are:

"The manic reaction with its feeling of well-being (or irascibility), flight of ideas and over-activity.

"The depressive reaction with its feeling of mental and physical insufficiency, a despondent, sad or hopeless mood and in severe depressions, retardation and inhibition; in some cases the mood is one of uneasiness and anxiety, accompanied by restlessness.

"The mixed reaction, a combination of manic and depressive symptoms.

"The stupor reaction with its marked reduction in activity, depression, ideas of death, and often dream-like hallucinations; sometimes mutism, drooling and muscular symptoms suggestive of the catatonic manifestations of dementia praecox, from which, however, these manic-depressive stupors are to be differentiated.

"An attack is called circular when, as is often the case, one phase is followed immediately by another phase, e.g., a manic reaction passes over into a depressive reaction or vice versa.

"Cases formerly classed as allied to manic-depressive should be placed here rather than in the undiagnosed group.

"In the statistical reports the following should be specified:—(a) Manic type; (b) Depressive type; (c) Stuporous type; (d) Mixed type; (e) Circular type; (f) Other types."

Diefendorf[279] states that manic-depressive insanity comprises from twelve to twenty per cent of the admissions to hospitals for mental diseases. He reports defective heredity as being shown in from seventy to eighty per cent of the cases. He also found about seventy-five per cent of the patients suffering from this disease to be of the female sex. Buckley[280] states that sixty per cent of the cases give positive histories of "familial neuropathy and psychopathy." Paton[281] is of the opinion that heredity is a factor in from eighty to ninety per cent of all cases. Hoch has called attention to the constitutional makeup of individuals subject to manic-depressive attacks and suggests that they are usually of a moody, morose type, unduly optimistic or temperamentally unstable. Kraepelin[282] found suicidal tendencies in 14.7 per cent of the female patients, and in 20.4 per cent of the men. Nine per cent of his cases showed a manic makeup; 12.1 per cent, a depressive temperament; 12.4 per cent were irascible or nervous; and from three to four per cent exhibited cyclothymic tendencies. Of the cases admitted to his clinic 48.9 per cent were depressive forms; 16.6 per cent, manic; and 34.5 per cent represented both types in various combinations. Melancholia simplex and gravis constituted 23.5 per cent of the simple forms, 13.5 per cent showed phantastic delusions and 6.1 per cent anxieties. Hypomanias made up four per cent, and acute mania, 9.8 per cent of the cases. Confused and stuporous states constituted 8.2 per cent and compulsions, one per cent. Lighter forms constituted ten per cent, and more severe types, nine per cent of the admissions. Stupors and clouding were found in 4.9 per cent and delusional states in 4.9 per cent of the total. He quotes Walker as reporting, in a study of 674 cases, that excitements contributed eleven per cent; depressions, 55.7 per cent; and circular forms 33.3 per cent of the male cases; and excitements, 6.2 per cent; depressions, 70.2 per cent; and circular types, 23.6 per cent of the female admissions. In from sixty to seventy per cent of Kraepelin's cases the first attack was a depression. In two-thirds of them, after the first mild attack there was a remission. In one-third of the cases, the depression terminated in an excitement followed by recovery. When the disease begins with a manic attack, two-thirds of the cases are followed by a remission. He reports excitements with a duration of ten years and depressions of fourteen years standing. In a study of 703 remissions he found ninety-six lasting from ten to nineteen years; thirty-four, from twenty to twenty-nine years; eight, from thirty to thirty-nine years; and one of forty-four years. He is of the opinion that the length of remission bears no relation to the duration of the attack. Of the depressions, 167 had a remission of six years; forty-six of 2.8 years; and twenty-seven of two years or more. Of the manic forms, fifty-three had remissions of 3.3 years; twenty-four of 4.5 years; and twenty of two years or more. Manic-depressive psychoses constitute from ten to fifteen per cent of the admissions at Kraepelin's clinic. He found hereditary taint in eighty per cent of his Heidelberg cases and quotes Walker as reporting 73.4 per cent; Saiz 84.7 per cent; Weygandt, ninety per cent; and Albrecht, 80.6 per cent. A history of alcoholism was found in twenty-five per cent and syphilis in eight per cent of the male patients.

Rehm made an interesting study of the offspring of manic-depressives. Of forty-four children in nineteen families, fifty-two per cent showed evidences of psychic degenerations, twenty-nine per cent of which consisted in an abnormal emotional makeup usually of the depressive types. In 157 cases from fifty-nine families, Bergamasco found that 109 showed manic-depressive psychoses. Kraepelin noted that the highest percentage of the first attacks occurred between the ages of fifteen and twenty. Reiss made a very significant analysis of the various forms of the disease manifested by individuals possessing definite predisposition. Thus, of the cases with a depressive makeup 64.2 per cent had depressive attacks, 8.3 per cent, manic, and 27.5 per cent, combined forms. Of those with manic temperaments, 35.6 per cent had depressive attacks, 23.3 per cent, manic, and 41.1 per cent, combined forms. Of the irritable individuals, 45.5 per cent had depressive attacks, 24.4 per cent, manic, and 30.1 per cent, combined forms. Of the cyclothymic persons, 35.3 per cent had depressions, 11.7 per cent, excitements, and fifty-three per cent, combined forms.