PART II — часть 7

Pollock and Nolan[312] have made a study of 9,124 admissions of dementia praecox to the New York hospitals during a period of six and three-quarters years. Of these cases 52.2 per cent were men and 47.8 per cent, women. The distribution shown by age groups is interesting and significant, as is shown by the following table:—

This would not appear to suggest an adolescent origin for this disease to the extent advocated in our textbooks. The highest rate shown by males was in the age group from twenty-five to twenty-nine years and in the female cases, from thirty-five to thirty-nine years. Forty-nine per cent were thirty years or over at the time of admission, forty-three per cent were between twenty and thirty years of age and thirty per cent, between thirty and forty. Nineteen per cent were forty years or over at the time of admission. Pollock's[313] investigation, the most exhaustive statistical study yet made of dementia praecox, shows that fifty per cent of the cases have a family history of insanity, nervous diseases, alcoholism or neuropathic or psychopathic traits, with a full fifty per cent showing no evidence of unfavorable heredity. This again is at variance with opinions usually expressed on this subject. Forty-six per cent were of normal mental makeup and seventy-eight per cent intellectually normal before the onset of the psychosis. Alcohol was an assigned etiological factor in four per cent of these cases and there was a history of intemperance in eight per cent of the others. The incidence of dementia praecox is more than three times as great in cities as it is in the rural districts. The average length of hospital residence was sixteen years. The foreign born dementia praecox first admissions were found to be principally from Austria, Germany, Hungary, Ireland, Italy and Russia. Fifty-one and four-tenths per cent of the cases were natives of this country and 48.3 per cent, of foreign birth. It is interesting to note that in 1919, 39.9 per cent of the first admissions to the New York institutions for the criminal insane were cases of dementia praecox. The rate of admission was 37.1 per cent in 1918, 20.5 per cent in 1917, 30.8 per cent in 1916 and 32.8 per cent in 1915. Of the 37,607 patients in the New York state hospitals on June 30, 1919, 22,036, or 58.8 per cent, were cases of dementia praecox. One hundred and thirty-eight were discharged as recovered during a period of three years. This number represented 5.2 per cent of the cases of dementia praecox discharged during that time, 2.01 per cent of those admitted, 1.1 per cent of all discharges, and .6 per cent of all first admissions. A review of the cause of death in 2,988 cases shows that the rate for tuberculosis was thirty-three per cent during four years when there was no influenza epidemic. This constituted over fifty-nine per cent of all of the deaths due to tuberculosis during that period of time.

Dementia praecox with the highest admission rate of any of the psychoses, its exceedingly unfavorable recovery rate, its extreme susceptibility to tuberculosis, and representing as it does over one-half of the population of our hospitals, must unquestionably be looked upon as the most important form of mental disease with which we have to deal today. The number of cases of dementia praecox in the Massachusetts and New York hospitals justifies the statement that there are approximately 120,000 persons suffering from this disease in the institutions of the United States, their maintenance alone costing the country twenty-five million dollars annually. Their permanent removal would make it possible to close at least sixty institutions larger than any state hospital in Massachusetts.

CHAPTER XIV

PARANOIA AND THE PARANOID CONDITIONS

A discussion of the part played by paranoia, or the paranoid conditions however characterized, in the psychiatry of the present day, is essentially a review of the final chapter in the history of a psychiatric conception which is several centuries old. The word paranoia, like many other terms still in use, is of Greek origin and was apparently applied by Hippocrates in a very general way to "madness" of any or all forms. It almost certainly had no more definite significance than that, in the works of Plato and Aristotle, nor can it be said to have been used in its modern sense by Celsus or Aretaeus. It seems to have meant something more in the vocabulary of Vogel, an eighteenth century writer. Under the heading of paranoia, according to Jelliffe,[314] Plocquet in 1772 included Paracope or delirium with six subdivisions:—(a) pathetica, (b) phronestica, (c) entomica, (d) encephalica, (e) hyperesthetica, and (f) sympathica. It was not recognized to any great extent by the earlier writers of the French school, but occupied a very prominent place in the development of German psychiatry. Heinroth in 1818 included the paranoias in his disorders of the intellect under the name of verrücktheit, a word that was destined to become one of great importance later, and spoke of an exaltation of the feelings which he called "paranoia ecstasia."

Flemming [315] in his elaborate classification of psychoses in 1844 described paranoid forms of "mania adstricta" or partial mania (monomania). Stark, a contemporary of Flemming's, made what seems to be a very direct reference to paranoia in his discussion of "Wahnsinn," as did Weiss in 1842. Von Feuchtersleben in 1845 wrote a very exhaustive description of "fixed delusions" which he classified as either involving the personality (mania metamorphosis) or as being ambitious, religious or relating to love (erotomania). He also spoke of a monomania or mania sine delirio which he attributed to Pinel. The exact significance of these conceptions cannot be determined.

In 1845 Griesinger used the word verrücktheit as applying to a secondary incurable condition, exhibiting delusions of persecution and grandeur and usually developing after an attack of mania or melancholia. He also defined Wahnsinn, which he compared to Heinroth's "paranoia ecstasia," as including "states of exaltation characterized by assertive, expansive emotions, associated with persistent excessive self-estimation and extravagant fixed delusions which arise therefrom." Magnan spoke of "folie systematisée progressive" and a "folie systematisée des dégénérés." In his "Le Délire Chronique à Évolution Systematique" he divided paranoia into a stage of subjective analysis, one of persecution and a third of transformation of the personality. Lasègue described this same condition under the name of persecution mania in 1852. Falret and Ritti divided the course of this disease into four periods, one of insane interpretations, one of visual hallucinations, one of general sensory derangement and a stereotyped state or mania of ambition. Morel was of the opinion that these psychoses were always preceded by an initial period of hypochondriasis.

Pritchard described as monomania a form of insanity "characterized by some particular illusion or erroneous conviction impressed upon the understanding, and giving rise to a partial aberration of judgment." Esquirol devoted as many as one hundred and thirty pages to a study of monomania, which he subdivided into seven forms:—the erotic, "raisonnante" or moral insanity, the alcoholic, the incendiary, the homicidal, the suicidal and the hypochondriacal.

It was probably the work of Mendel in 1881 which was responsible for the use of the word paranoia in its modern sense. He spoke of primary and secondary paranoias.[316] The former was described as a "functional psychosis characterized by the primary appearance of delusional ideas. The delusions of primary paranoia, without being interfered with by any opposing ideas, control the entire mental life of the patient. The remaining ideas not affected by morbid processes stand in close relation, but not in conflict, with the dominating delusions. The feelings are determined by the content of the delusions and vary with them. In the same way the abnormalities of conduct are due to the content of the delusional ideas, with or without hallucinations." Régis in 1892 described his systematized progressive insanity as involving three distinct stages,—one of subjective analysis, a stage either of persecution, religious exaltation or eroticism and jealousy, and finally a megalomanic state ending occasionally in dementia. Cramer, in an elaborate review of the literature of paranoia in 1894, refers to twenty-eight different designations used by various writers in the discussion of this subject up to that time. Serieux and Copgras (1909) include deliria of interpretation and of vindication in their grouping of these conditions.

In the words of Meyer, paranoia eventually reached its high water mark in the work of Krafft-Ebing. [317] He defined it as "a chronic mental disease occurring exclusively in tainted individuals, frequently developing out of the constitutional neuroses, the principal symptoms of which are delusions." These are devoid of all emotional foundation and from the beginning are systematized, methodic and "combined by the processes of judgment, constituting a formal delusional structure. Consciousness is not disturbed and judgment as a rule is not impaired but is entirely based on delusional premises." The conduct of the individual is determined by his hallucinations and delusions. The process of development is slow and the disease remains stationary for many years, but never ends in dementia. In a study of over one thousand cases Krafft-Ebing[318] never observed a definite recovery, although lucid intervals occurred, generally in the beginning of the disease. The taint of paranoia he describes as heredity, in the form of abnormal character, psychoses, constitutional neuroses and alcoholism. In a few instances he reported developmental defects in the brain. He found in all cases an anomaly of personality which determined the later form of the paranoia. Suspicious, retiring, solitary persons were usually persecuted. Rough, irritable, egotistical individuals developed the querulent forms and the over-conscientious eccentrics became the victims of religious paranoia. He attaches a considerable importance to the influence of the unconscious or subconscious mind. "Its predominance is shown in the dreamy, romantic, enthusiastic life of such individuals, and in the fact that accidental delusions occurring in sickness, dream pictures, and reminiscences from reading or plays, are elaborated in the depths of the soul, and early burst forth in the form of imperative ideas and desultory primordial delusions, which become latent, but later find their ultimate evaluation in the delusional ideas of the disease."

It is interesting to note that Krafft-Ebing speaks of precipitating factors as puberty, the climacteric, uterine disease and onanism. There is a definite period of incubation followed by one of full development in which judgment and reason are lost. Hallucinations of hearing were found to be the more common form, followed in the order of their numerical occurrence by disturbances of sensibility, vision, taste and smell. Persecutory ideas, moreover, were said to be much more frequent than delusions of grandeur. The terminal states he speaks of as mental enfeeblements with a prominence of emotional dulness, rather than intellectual defects. He divides the disease into original paranoia and the later or acquired forms. Original paranoia begins before or at latest during puberty. Hereditary taint is always to be found. Conspicuous features are sentimental tendencies inclining to hypochondria, eroticism with sensitiveness and emotional instability. Delusions as to parentage are common, suggested often by the fancied or real resemblance of the patient to pictures of distinguished personages. Transitory ideas of persecution or grandeur are nearly always present. The erotic element is more frequent in females. Intermissions sometimes last for years. The termination is often found in confusional states. The classic or acquired form of the disease develops later in life, often during the involution period. Two varieties are described,—the persecutory and the expansive. Subsidiary types of the former are sexual paranoia, often with delusions of jealousy, and querulous insanity with mania for lawsuits. The sexual complex he attributes largely to masturbation or enforced abstinence. The expansive group is divided into inventive or reformatory paranoia, the religious and the erotic varieties (erotomania). The acquired form as described by Krafft-Ebing is quite similar to the "folie systematisée" of Magnan. It conforms, moreover, in a general way to the views expressed in the English textbooks on delusional insanity and is the paranoia of Spitzka, Chapin, Berkley, Peterson and many other American psychiatrists. This conception of the psychosis was the generally accepted one for many years.

The institutional reports of that day showed large numbers of paranoics in some of the hospitals. It was a disease that played an important part in many murder trials and has received more attention from the courts and newspapers than any other form of insanity, so-called, ever described in the textbooks. There was a time, according to Kraepelin, when from seventy to eighty per cent of the patients in the German hospitals were diagnosed as cases of genuine paranoia. Certainly that cannot be said of the institutions of this country. In the New York state hospitals, for instance, during a period of sixteen years, from October 1, 1888, to September 30, 1904, when the classical form of paranoia was officially recognized in statistics, 84,152 admissions were reported. Of this number 1,655, or 1.9 per cent, were diagnosed as cases of paranoia. At the Matteawan State Hospital for the criminal insane during this time 1,728 admissions were shown, with no cases of paranoia. At the Dannemora State Hospital for insane convicts during the same period there were 354 admissions, sixteen, or 4.51 per cent, of which were paranoiacs. This is exceedingly interesting but extremely difficult to explain. It is very hard to understand why no cases of paranoia reached Matteawan during a period of sixteen years. The percentage shown in the other institutions can be looked upon as being fairly representative of the incidence of paranoia as the disease was then understood.

The decline and fall of the paranoia concept is to be attributed to Kraepelin. In 1893 his classification included hallucinatory and depressive forms of "Wahnsinn," both accompanied by persecutory ideas to a rather prominent degree, and paranoia proper, which he described as "Verrücktheit." This was defined as the "chronic development of a permanent delusional system with complete preservation of consciousness". In the sixth edition of his well-known textbook, which appeared in 1899, he enlarged the dementia praecox group previously described by him and added hebephrenia and katatonia to it as well as describing a new and important "paranoid" form of that disease. His own reasons for this were stated as follows[319]:—"The second clinical group" (dementia praecox, paranoid form) "which I am inclined, provisionally, to include under this head, is characterized by the fact that extravagant delusions, usually accompanied by numerous hallucinations, develop in a more coherent manner, and are maintained during a series of years, either then entirely to disappear, or to become entirely confused. Hitherto I have reckoned these forms, as 'phantastische Verrücktheit' to paranoia, as is the general practice. It has, however, gradually become clearer to me that they are at all events, more nearly allied to dementia praecox than to paranoia. Whether we really have to do in this case only with a clinical variety of the former disease or a distinct malady, the future must decide." He did, however, at that time still recognize a small but well defined group of cases as genuine paranoia. "On the other hand, there is, without doubt, a group of cases, in which it is clearly recognizable from the outset that a permanent, immovable system of delusions slowly develops, with entire preservation of mental clearness, and of the regulation of the course of thought. It is these forms for which I would reserve the appellation of paranoia. It is they which necessarily lead to a profound transformation of the entire view of life; to a dislocation of the point of view which the patient assumes toward the persons and events of his environment." In the eighth edition of his book (1913) he separates out a considerable number of cases and places them in an entirely new group designated as "paraphrenias."[320] This is "a comparatively small group in which, in spite of many similarities to the manifestations of dementia praecox nevertheless on account of the much less marked development of emotional and volitional disturbances the inner structure of the mental life is considerably less affected, or in which at least the loss of inner unity is essentially limited to certain intellectual functions. Common to all of these clinical forms which cannot be sharply differentiated is the marked prominence of delusion formation and the paranoid colouring of the disease process. At the same time there are also alterations in the disposition, but not until the last stages of the disease that dulness and indifference which so often are the first indications of dementia praecox." In other words, we are dealing with a group which shows the paranoid features of dementia praecox but largely lacks its deteriorative processes. This is a very decided change of views and may be looked upon either as establishing a definite status for a large number of cases not properly accounted for in the past or as an indication of a tendency to return to former conceptions of paranoia.

Of the paraphrenias as described by Kraepelin "approximately one-half show that slow but progressively developing mixture of delusions of persecution and grandeur which Magnan has described under the designation of 'délire chronique à évolution systematique.' Certainly this disease of Magnan's, as far as can be determined from the descriptions available, is not a clinical entity in the sense of the views expressed here; we would unhesitatingly include with the paranoid forms of dementia praecox many of the cases, with well developed mannerisms and the coinage of new words, which progress rapidly to mental enfeeblement. At the same time, however, 'délire chronique' with its slowly progressing forms lasting for decades includes a number of cases which form the nucleus of the first paraphrenic disease group to be described." Whether or not the paraphrenia of Kraepelin is accepted as having been established, it must be conceded that the question as to whether anything remains of the original paranoia group is one worthy of serious consideration. Many have discarded the term entirely.

Kraepelin's paraphrenia is divided into the following forms:—systematica, expansiva, confabulans and phantastica. The systematic type is characterized by "the extremely insidious development of continuously progressing delusions of persecution, with the later appearance of delusions of grandeur without deterioration of the personality." The expansive form shows "the prominent development of delusions of grandeur with a predominant exalted mood and mild excitement." The confabulans variety is a small group "distinguished by the prominent rôle played by falsifications of memory." The phantastic form shows "a marked development of phantastic, unsystematized, changeable delusions." This was the paranoid dementia praecox of his sixth edition. Of the cases heretofore assigned to the paranoia group Kraepelin has expressed the opinion that about forty per cent belong to dementia praecox. "A further somewhat larger part falls to the paraphrenic forms to be described here." The practically negligible remainder he apparently concedes to genuine paranoia. In his eighth edition Kraepelin states that the latter constitute less than one per cent of all admissions. He now limits the term paranoia to cases arising from purely internal causes and showing a slowly developing permanent system of delusions without any disturbance of thought, volition or conduct. The delusional formations may be of various types,—persecution, jealousy, self-importance (great inventions, ideas of noble birth, etc.) or they may be of a religious or erotic nature. The "querulents" he now classifies with the psychogenic disorders. His present conception does not admit of the association of paranoia with hallucinations.

The most interesting and important feature, perhaps, of Kraepelin's presentation is his insistence upon internal causes only as etiological factors. He assumes a psychopathic foundation for the development of the disease. In more than one half of his cases he found well marked personal peculiarities. These were manifested in some instances in the form of irritability, excitability and abnormalities of conduct. Other individuals were suspicious, unreliable, lacking in will power and over-ambitious. Homosexual tendencies were not infrequent. External factors, such as unpleasant experiences, may influence the form of the delusional expressions but should not be looked upon as explaining their origin. They develop in an emotional soil definitely related to the hopes and fears of the healthy individual and are to be looked upon as a morbid transformation of perfectly normal mechanisms. In addition to this he speaks of an increased self-consciousness, a natural tendency to resistiveness, an undeveloped type of thinking, psychological compensations for the disappointments of life, evidences of developmental inhibitions, improper habits of thought leading to morbid conceptions, etc. He refers to exaggerated self-consciousness as the fundamental basis of paranoia. In this soil delusions develop as a result of inadequate intellectual processes due to developmental inhibitions. All of these views have been elaborated more fully in his recent discussions of the subject of "comparative psychiatry."[321] These mechanisms, he says, have not escaped the notice of the Freudian school. Kraepelin feels, however, that their arguments "are not based either on a clear conception of paranoia or on any evidence at all acceptable."

Bleuler's theory of the disease is summed up in the following quotation from his "Affectivität, Suggestibilität, Paranoia"[322]:—"The exact observation of the objective and subjective relations at the time of the origin of the disease shows us therefore nothing more than the appearance of errors, such as occur to normal persons under analogous affects and a connection of accidental occurrences to a thought complex which is kept continually awake by defects and his own trends of thought, just as it is in a corresponding normal mental process. The pathological feature is only the fixation of the error so that it becomes a delusion, and then the further extension of the delusions so that it finally becomes paranoia." In 1906 when this was written he suggested no explanation for the extension of such errors and their fixation in an actual psychosis. This might readily be interpreted as a logical result of the paranoic "constitution."

The development of paranoic states was summarized by Meyer [323] as follows:—" a. Feeling of uneasiness, tendency to brooding, rumination and sensitiveness, with inability to correct the notions and to make concessions—paranoic constitution and paranoic moods. b. Appearance of dominant notions, suspicious or ill balanced aims. c. False interpretations with self-reference and tendency to systematization, without or with d. Retrospective or hallucinatory falsifications, etc. e. Megalomanic developments or deterioration or intercurrent acute episodes. f. At any period antisocial and dangerous reactions may result from the lack of adaptability and excessive assertion of the sidetracked personality."

Freud sees in paranoia a reversion to the homosexuality of the developmental period of the individual with a projection of symptoms resulting from mental conflicts due to a repression of complexes. He described the sexuality of the infantile period as being purely autoerotic in character, the sexual interests of the child being centered in its own body. From this stage the object of interest is gradually transferred to other individuals of the same sex, the normal attraction to the opposite sex being a final development of later years. Freud believes that in paranoia there is a fixation in one of these early transitional stages. "Persons who cannot rise completely out of the stage of narcissism and are thus prematurely fixed or arrested in the evolution of their dispositions, are exposed to the danger that a flood of libido which finds no outlet, sexualizes their social tendencies and reverts the sublimations achieved in the course of the development."[324] The resulting mechanisms may be looked upon as defense reactions. The subconscious homosexual longings of the individual are repressed but finally admitted to full consciousness in the form of a projection, the sexual object usually being accused of persecution, thus justifying the attitude of the paranoic towards the cause of his troubles. In erotomania the antagonism is directed not against the homosexual object but upon some person of the opposite sex. Freud interprets the delusions of jealousy of the alcoholic as an evidence of homosexual attraction, the individual justifying himself by the charge that it is his wife and not himself who is the guilty one. The delusions of grandeur he looks upon as a sweeping denial of all extraneous influences, the individual building a defense for himself by assuming a self-aggrandizement that leaves no room for homosexual objects. Perhaps these mechanisms are, as Meyer suggests, only another expression of the well recognized and more or less normal tendency to accuse others of being at fault in some way when what we do ourselves goes wrong. Certainly, if nothing more, they are exceedingly ingenious and interesting theories. One cannot but be impressed by the extraordinary skill of Freud in discovering the sexual origin of almost any mental process with which we are familiar. The ready facility with which his study of sexual conflicts and repressions can be shown to serve as a complement to the anatomical, symptomatic, and prognostic hypotheses of Kraepelin is also worthy of note.

As has already been said, there is considerable question as to how much, if anything, remains of the old-time paranoia concept. The uncertainties attending diagnosis have given rise to the modifying term "paranoid" which has been very generally used for many years. It should be remembered that paranoia when at its best only constituted approximately two per cent of all psychoses reported from institutions. These various considerations have resulted in its not having a distinctive place in the classification adopted by the American Psychiatric Association and it has been given official recognition as follows:—

"From this group should be excluded the deteriorating paranoid states and paranoid states symptomatic of other mental disorders or of some damaging factor such as alcohol, organic brain disease, etc.

"The group comprises cases which show clinically fixed suspicions, persecutory delusions, dominant ideas or grandiose trends logically elaborated and with due regard for reality after once a false interpretation or premise has been accepted. Further characteristics are formally correct conduct, adequate emotional reactions, clearness and coherence of the train of thought."

A study of the statistics of American hospitals shows quite clearly the importance which should be attached to the paranoid conditions. During 1918 and 1919 there were 13,588 admissions to the thirteen New York state hospitals. Two hundred and fifty-six, or 1.88 per cent, of these were cases of paranoia or paranoid conditions. During a period of eight years there were 49,640 admissions of which 1,240, or 2.5 per cent, were paranoid conditions. In Massachusetts sixty-four, or 2.12 per cent, of the 3,011 admissions during 1919 were reported as paranoid conditions. In twenty-one hospitals in other states there were 18,336 admissions. Of these, 789, or 4.3 per cent, were paranoid conditions. These statistics show quite a small admission rate for these psychoses in New York and Massachusetts. The rate in other state hospitals is noticeably higher. As the percentage for dementia praecox is considerably lower in the reports from these institutions than it is in Massachusetts and New York, it is fairly reasonable to assume that many cases shown as paranoid forms of dementia praecox in Massachusetts and New York are classified with the paranoid conditions in the other states. If we consider the total admissions from all of the hospitals in question, we find 2,093 paranoid conditions in all, constituting 2.94 per cent of a total of 70,987 cases. It has already been shown that paranoia, at a time when it was a well recognized entity, constituted only 1.9 per cent of over eighty-four thousand consecutive admissions. This clinical grouping has, therefore, obviously been enlarged by adding paranoid conditions which could not probably be classified as well recognized types of other psychoses.

CHAPTER XV

THE EPILEPTIC PSYCHOSES

Ancient history contains numerous references to epilepsy. The "Morbus sacer" of the Romans was apparently a subject of great interest to Hippocrates,[325] who wrote, over two thousand years ago, "The sacred disease appears to me to be no wise more divine nor more sacred than other diseases; but has a natural cause, from which it originates like other affections. Men regard its nature and cause as divine from ignorance and wonder, because it is not at all like other diseases." Presumably for a somewhat similar reason the disease was also referred to as the "Morbus Sideratus," it being thought that those affected were "star struck" or smitten in some mysterious and supernatural manner. By others it has been suggested that the theory regarding the divine origin of the disease was attributable to the seizures which always preceded the prophesies of the priests of Apollo. Herodotus is responsible for the statement that Cambyses, the king of the Persians, was subject to the "sacred disease" from birth. Such historians as Hippocrates and Euripides have definitely established the status of Hercules as a confirmed epileptic. "Morbus Herculeus" was one of the earliest designations of the disease. It was referred to by Plutarch in his writings. Suetonius describes the emperor Caligula as unquestionably afflicted with epilepsy. No less an authority than Lombroso speaks of Napoleon, Molière, Julius Caesar, Petrarch, Peter the Great, Mohammed, Händel, Swift, Richelieu, Charles V. Flaubert, Dostoieffsky and St. Paul as all being victims of the same affection. Truly this is a noble assemblage,—one which might readily make the disease fashionable!

Maudsley ("Body and Mind") was convinced that Swedenborg suffered from a form of epileptic insanity. The following quotation from his diary would lend some color to that theory:—"There happened to me something very curious. I came into violent shudderings, as when Christ showed me His Divine Mercy. The one fit followed the other ten or fifteen times." After his fifty-fifth year, according to Maudsley, Swedenborg was permanently insane. The historian Sloan in his "Life of Napoleon" accepts as an established fact the statement that this great military strategist was an epileptic. Appian's "Roman History" certainly justifies Lombroso's reference to Julius Caesar: "At length, whether he lost all hope, or else for the better preservation of his health, never more afflicted with the falling sickness and sudden convulsions than when he lay idle, he resolved upon a far distant expedition against the Gatae and the Parthians." Washington Irving in speaking of some of the peculiar experiences of Mohammed suggests that, "Some of his adversaries attributed them to epilepsy." Even a very brief review of the historical aspects of this disease should perhaps not omit the contribution made by Shakespeare: "My Lord is fallen into an Epilepsie. This is his second Fit." (Othello)

Epilepsy and the mental disturbances associated with it are so intimately related that they can hardly be considered separately. Notwithstanding that fact it must be admitted that there is no sharply circumscribed clinical entity properly definable as epilepsy. Nor is there anything distinctive about the psychotic manifestations occurring during the course of that disease, although Tuke's Dictionary mentions over thirty different varieties. In the most exhaustive study of epilepsy ever made in this country Spratling[326] reported that memory defects were noted in ninety per cent of the patients examined by him. It should be borne in mind that the group studied did not include any committed mental cases. He found from eight to ten per cent so slightly affected as to be legally "sane," "except at the brief moment of attack." Fifty per cent were mentally incompetent with rational intervals and forty per cent were "continually irresponsible." This latter class included from twenty to twenty-five per cent of imbeciles and idiots and from fifteen to twenty per cent recognizable as insane "by law and medicine alike." The prevalence of mental disease in a hospital population composed exclusively of epileptics is shown by his statement that of 801 patients examined at Craig Colony forty-one could not tell their own names; 166 did not know their age; 267 could not name the year, 263 the month, and 226 the day of the week; 238 did not know where they were; 378 were unable to state the year of their birth, 183 the last place of residence, 219 the name of the institution, and 248 the length of time there; in addition to this, 224 could not write well enough to sign their own names. It is interesting to note that the disease had its onset in 38.5 per cent of his cases before the age of ten years, in 43.5 per cent between the ages of ten and twenty, and in 9.5 per cent between the ages of nineteen and twenty-nine. Gowers found that seventy-six per cent developed symptoms before the age of twenty. Spratling classified the mental conditions found in epileptics as follows:—Psychic epilepsy, epileptic automatism, pre- and postparoxysmal mental disturbances, paroxysmal states (epileptic mania), and interparoxysmal conditions. The latter included transitory ill-humor, slight dulling or clouding of the intellect, feeblemindedness, imbecility, idiocy, epileptic dementia and acute confusional insanity which he says belongs to the manic-depressive group. He warns against the danger of classifying as dementia conditions due entirely to the use of bromides.

L. Pierce Clark[327] looks upon epilepsy as the logical development of a well defined individual make-up described as the "epileptic constitution" and existing from the earliest childhood. In support of that theory he has reviewed the contributions of other writers on this subject. He found that Vogt called attention to the epileptic "poverty of ideas, prolonged reaction time, egocentricity, many religious reactions and acts of servility." Jung referred to a series of superficial associations, influencing the ideas of the patient, somewhat similar to those occurring in imbecility and sometimes observed in normal individuals of the uneducated class. Roemer speaks of a disturbance of "secondary identification" involving memory pictures with special sense recognition unimpaired. Eintinger described an essential poverty of affectivity and Wiersma, periodical variations in attentiveness. Ritterhaus defined the epileptic mental content as one of poverty of ideas, prolonged reaction time, egocentricity, emotional reactions and circumstantiality. Arndt included in the epileptic character peculiar inward fervor, characteristically egotistic in nature, and resembling the alcoholic temperament. Bianchi believed that the disease developed on a personality basis strongly suggesting the criminal type. He spoke of an inadaptability to the environment, the preponderance of individualistic instinct, cruelty, laziness, evil life, precocious and excessive development of the sexual instinct, irascibility and impulsiveness. Turner described an epileptic "temperament." He found these individuals to be egotistical, conceited, pretentious in conversation, emotionally unstable and sometimes obstinate or over-religious. Hartmann and di Gaspero noted as prodromal manifestations, abnormal changes of temper, excitability, anxious fears, sudden depressions, restlessness, irritability, distrust, memory falsifications, and violent impulses. Voisin found that less than ten per cent of epileptics showed a perfect balance in the emotional make-up. Hübner expressed the opinion that true dipsomania occurs chiefly in epileptics. He found alternations in the character of the individual in from ninety to ninety-five per cent of his cases.

Clark's[328] conclusions were summarized by him as follows:—"1. There is more or less constant affective defect in all epileptics, sane as well as insane; that such defect is due to an inherent make-up of the psyche in which mainly an egocentricity and a highly sensitized feeling are given to the individual; and that from this constitutional make-up or alteration the ultimate deterioration of the psyche, intellectually as well as emotionally, is gradually developed, step by step, and if the state is not corrected that this finally and logically ends in so-called epileptic dementia. 2. The epileptic alteration is seen to proceed from the mental make-up or constitution of the individual epileptic long before his malady reaches the convulsive stage and that the one is but a further and final unfoldment of the former." As Clark expresses it, "The nucleus of this personality defect is a temperament of extreme hypersensitiveness and egotism and all that these two main characteristics entail ... a personality defect which makes its possessor incapable of social adaptation in its best setting and which, if it remains uncorrected, renders the individual inadequate to make a normal adult life." He looks upon the epileptic reaction as a "more or less direct outcome of the epileptic's inability to stand the stress and harassments of life from which he seeks automatic or unconscious withdrawal." This exhibits itself as a loss of spontaneous interest, day-dreaming, lethargy, somnolence, etc., terminating finally in epileptiform attacks when the strain becomes too great. A rather complete description of the "epileptic character" appeared in Schüle's "Klinische Psychiatrie" in 1886.

An analysis of these mental mechanisms leads naturally to certain therapeutic indications. In view of the history of the bromide therapy, since the time of its introduction by Laycock as the ideal form of treatment in 1851, such suggestions should be given serious consideration. Clark advocates the early use of educational methods in correcting the defects of the epileptic constitution. Thus he would obtain control of the egocentricity and hypersensitiveness by reducing environmental stresses, teaching adjustment to the surroundings, and finding suitable and normal outlets for the spontaneous desires of the individual. He is of the opinion that in the apparently deteriorated cases mental interests can be restored and emotional and mental dilapidation greatly improved. He has reported a series of cases showing that the frequency and severity of seizure can be greatly influenced "with the more or less permanent arrest of the disorder in not a few cases."[329] A subsequent study of the mental mechanisms involved was summarized by Clark[330] in these words: "It is fairly obvious that the mental content in epilepsy proves that the epileptic regresses from the displeasurable difficulties of life, and in the first states of the fit the stress alone may be uncovered; whenever the patient reaches a deeper unconscious state, he gains the level of an easily recognized sexual striving."

Kraepelin[331] would differentiate between "symptomatic" forms of epilepsy due to organic diseases, injuries or growths; and the "genuine" variety not associated with any coarse brain lesion. He describes as indications of impending attacks, occurring several hours or even days before, headache, irritable ill-tempered moods, general discomfort, weakness, palpitations, oppression, anxiety, vertigo, nausea, hot and cold sensations, sense deceptions of various kinds, muscular twitching, sexual excitement, disturbed sleep, unpleasant dreams, etc. Binswanger found these symptoms present usually in the severer forms of the disease. Finkh found them in twenty-five per cent of his cases. Psychic, sensory, motor and vasomotor aura are described. Kraepelin after discussing first the paroxysmal attacks occurring in the disease speaks of the various forms of psychic epilepsy as constituting the second important group of clinical manifestations to be considered. These conditions may be looked upon as pre- or post-epileptic insanity, depending on their relation to convulsions, or may be entirely independent of them or considered as equivalents.

The most common form of psychic epilepsy he describes as periodical ill-humor. It begins sometimes with sexual excitement (Ducosté). The patient becomes moody, surly, irritable, quarrelsome, gives up his work, refuses to eat and complains of everything around him. In some cases uneasiness, gloom or depression are manifested and suicidal tendencies may develop. Consciousness is clear although the patients complain that they cannot think or are confused and forgetful. Some have headache, perspire, show dilated pupils, vasomotor disturbances, nausea, etc. The picture is often complicated by alcoholic indulgence with attacks resembling dipsomania. This sometimes results in an epileptic clouded or dream state in which the patients become blustering, abusive, and violent or make senseless journeys. They may manifest a sudden impulse to wander from place to place without any apparent reason. Sexual excitement frequently occurs, with masturbation and exhibitionism, attacks on children or homosexual tendencies. Usually there is no recollection of these episodes. Occasionally expansive or ecstatic moods appear and rarely a flight of ideas is noted. These attacks of ill-humor usually last from a few hours to several days, often disappearing suddenly. Alcoholism always lengthens the duration. In some cases active hallucinations and clouding of consciousness occur. Dreams are common. Others show anxious states with hallucinations and sometimes well marked delusions. An actual delirium may appear, although usually only for a very short time. The hallucinations and delusions may persist for months, suggesting dementia praecox.

A second large group shows a more marked clouding of consciousness. These are the characteristic twilight or dream states of epilepsy. Thought is confused, desultory, retarded or incoherent. Sometimes there is a tendency to rhyme and repeat questions, or even a genuine flight of ideas. The mood may be depressed, anxious or irritable, although ecstatic states occur. The patient may become quiet, inaccessible, stuporous or cataleptic. Some, however, become excited. Later, defects of memory occur and amnesic periods may extend over a considerable length of time. The patellar reflexes may be increased and the pupils dilated and sluggish. There may be a contraction of the field of vision or disturbance of color sense, tactile sensation, smell and taste, with muscular weakness, Babinski reflexes, speech defects, dizziness, uncertain gait, nystagmus, etc. Somnambulism is sometimes encountered in epilepsy, although it is strongly suggestive of hysteria. The great majority of cases present the picture of a simple dreamy stuporous condition. Apprehension is clouded, the patients become confused, cannot control their thoughts, mistake the persons around them, lose themselves on the street, and wander away. They destroy their clothes, undress in the street, etc. Sexual excitement, exhibitionism and masturbation are common. Characteristic dream states may appear as equivalents.

A delirious confusion with hallucinations and delusions often develops. Some cases have a very strong religious coloring and believe themselves to be in heaven or hell—hear the voice of God, angels, etc. Grandiose ideas may appear and wonderful adventures are narrated. The mood is variable and may be either anxious, cheerful or erotic. There is a marked tendency to violence and the patients may be very restless and agitated. Delusions are common and often lead to suicidal attempts. Some exhibit an anxious delirium accompanied by numerous hallucinations. The patient is clouded as well as disoriented and delusions develop early. Fabrications sometimes appear in this condition. These deliria may last a few hours or several weeks. Profound and more or less long continued epileptic stupors may complicate the situation.

A "conscious delirium" of longer duration is observed in some instances. The sensorium is not so much clouded, and the patient appears quite clear. Hallucinations and illusions usually develop early in the attack. Pleasurable, grandiose ideas often appear. The attitude in a general way resembles that of a confused disorientation. Anxious moods may develop, or rarely cheerful tendencies. Consciousness becomes dreamy, with hallucinations of a religious coloring. Patients with an apparently clear sensorium may commit numerous foolish or even criminal acts without any apparent insight into their significance. Such conditions as this may last weeks or months. Self-accusation may occur between attacks. These individuals are quite likely to start on absolutely aimless journeys which may be the outcome of an alcoholic debauch. The dream state in such cases may have a decided alcoholic coloring with characteristic hallucinations or humorous tendencies. This may be mixed with religious ecstatic manifestations. Dream states only occur once or twice during the lifetime of an epileptic or may be comparatively frequent. Many patients never have them.

Aschaffenburg found fainting attacks in seventy-four per cent, convulsions in forty-two per cent, stupors in forty-four, petit mal in fifty-eight, dream states in thirty-six, and ill-humor in from sixty-four to seventy per cent of his cases. In his Munich clinic Kraepelin studied 515 epileptics. Eighty-six and eight-tenths per cent of them had attacks of unconsciousness, probably often reported as convulsions, 23.3 per cent had dizzy spells, 9.7 per cent stupors, 15.1 per cent petit mal, 3.3 per cent attacks of various kinds without unconsciousness, 16.5 per cent dream states, 1.9 per cent somnambulisms, 36.9 per cent ill-humor, 13.8 per cent excitements, mostly alcoholic complications, and 2.5 per cent had status epilepticus.

An epileptic weakmindedness develops in many cases. The field of thought is contracted and egocentric in character with delayed associations as shown by Jung. The patient is egotistical, interested in petty details, and strongly inclined to religious tendencies. He always minimizes the severity of the disease which, in his opinion, is improving rapidly. He is likely to develop mild paranoid ideas and feels that he has been mistreated or that others are prejudiced against him. These individuals are usually moody, irritable, dull, emotionally unstable and excitable. They are often overactive but not industrious. Many show a persistent "wanderlust." Werther reported that between seven and eight per cent of his cases were tramps or beggars. Quite a few show criminal tendencies. They nearly always have a marked susceptibility to alcohol which greatly aggravates their symptoms. Kraepelin is inclined to look upon the epileptic personality as a result of the disease and not the soil in which it develops.

In the more advanced deteriorations or epileptic dementias there is a marked mental dulness with poverty of thought, loss of memory, irascibility and occasional violence. Kraepelin refers to a genuine "epileptic physiognomy" which is often observed. Strabismus, nystagmus, ptosis, tremors and many other neurological symptoms are frequently found. Clark and Scripture have described a characteristic "voice" in epilepsy. Besta found a subnormal temperature in sixty-six per cent of his cases. Very elaborate studies of the blood have been reported from time to time. The secretions and excretions have been made the subject of exhaustive research and the changes in metabolism have been gone into thoroughly.

The pathology of epilepsy has been given careful consideration by Alzheimer. In cases of status epilepticus he found extensive acute alterations, more particularly in the Betz cells, with swelling of the neurones, crumbling of the Nissl bodies, and dislocation of the nucleus to the apex. Here and there the ganglion cells were entirely destroyed and others showed regressive changes. Karyokinetic figures are seen in the glia cells, which are usually swollen, show ameboid changes and contain degenerative products. Accumulations of broken down cell products are found around the vessels. A sclerosis of the cornu ammonis, usually unilateral, was reported by Bourneville in 14.8 per cent, by Pfleger in fifty-eight per cent, and by Alzheimer in from fifty to sixty per cent of the cases of epilepsy examined. This consists of an atrophy of the cells in a well defined area and their replacement by a network of fibres. The cells are shrunken or entirely gone, while there is a great increase in the neuroglia elements with many free nuclei. The walls of the vessels are thickened and "stäbchenzellen" appear. The significance of these findings is not known. Nissl looks upon them as only a part of a general involvement of the cortex. Widespread cell changes were frequently reported by both Nissl and Alzheimer. A marked increase in the neuroglia has been found particularly in the superficial layers of the cortex,—the so-called "marginal gliosis" of Chaslin. The vessels show an intimal proliferation and a thickening of the walls, with occasional mast-cells in the lymph spaces. Ranke has called attention to the presence or persistence of "Cajal" cells in the ordinarily cell free layers of the cortex. These are large transversely placed ganglion cells, common in the superficial layers of the cortex of the newborn but not found in the normal adult brain. This condition is looked upon as a cortical development defect. These so-called "Cajal" cells are also found in some of the mental deficiencies. Nevertheless it must be conceded that there are no definitely characteristic pathological changes so constant as to render certain the differentiation of this disease postmortem.

No forms of insanity perhaps are clinically so difficult and unsatisfactory from the standpoint of classification as are the epileptic psychoses. The various mental manifestations of the disease may very logically be described as: 1. Pre-paroxysmal episodes, 2. Paroxysmal states, 3. Post-paroxysmal episodes, 4. Inter-paroxysmal conditions to be specified, as excitements, depressions, anxieties, confusion, stupor, dream states, paranoid conditions, etc., and 5. Epileptic deterioration. There is some question as to whether the various psychic epilepsies, so called, are sufficiently clear-cut to constitute clinical entities.

The delimitation of these psychoses for statistical purposes is described in the Association's manual as follows:—

"In addition to the epileptic deterioration, transitory psychoses may occur which are usually characterized by a clouded mental state followed by an amnesia for external occurrences during the attack. (The hallucinatory and dream-like experiences of the patient during the attack may be vividly recalled.) Various automatic and secondary states of consciousness may occur.

"According to the most prominent clinical features the epileptic mental disorders should therefore be specified as follows:—

"(a) Epileptic deterioration: A gradual development of mental dullness, slowness of association and thinking, impairment of memory, irritability or apathy.

"(b) Epileptic clouded states: Usually in the form of dazed reactions with deep confusion, bewilderment and anxiety or excitements with hallucinations, fears and violent outbreaks; instead of fear there may be ecstatic moods with religious exaltation.

"(c) Other epileptic types (to be specified)."

During a period of sixteen years in the New York state hospitals (ending October 1, 1888) 3,167 of 84,152 admissions were cases of "epilepsy with insanity." This meant an admission rate of 3.76 per cent. It must be borne in mind, however, that the differentiation between epilepsy with insanity and psychoses clearly due to epilepsy was not attempted at that time. During a subsequent period of eight years in the same institutions, when what is essentially the present classification was in use, the admission rate for epileptic psychoses was 2.42 per cent. In 1919 with 3,011 first admissions to the Massachusetts state hospitals only fifty cases (1.66 per cent) were reported as showing psychoses due to epilepsy. Six hundred and twelve cases, constituting 3.33 per cent of 18,336 first admissions, were reported by twenty-one hospitals in other states. An analysis of a total of 70,987 first admissions in forty-eight state hospitals therefore showed that 1,865, or 2.62 per cent, were epileptic psychoses. After reading the statements contained in various textbooks regarding the extraordinary frequency of epileptiform seizures in dementia praecox, it is difficult to escape the conclusion that the percentage of epileptics has been underestimated rather than exaggerated.

CHAPTER XVI

THE PSYCHONEUROSES AND NEUROSES

The words neurosis, psychosis and psychoneurosis are of obscure origin and have had a varied significance from time to time. Murray[332] defines psychosis as a psychological term indicating "a change in the psychic state; an activity or movement of the psychic organism, as distinguished from neurosis" which he speaks of as a "change in the nerve-cells of the brain prior to, and resulting in, psychic activity." Huxley in discussing this subject in 1871 made the following differentiation: "In all intellectual operations we have to distinguish two sets of successive changes—one in the physical basis of consciousness and the other in consciousness itself; one set which may, and doubtless will, in course of time, be followed through all its complexities by the anatomist and the physicist, and one of which only the man can have immediate knowledge. As it is very necessary to keep a clear distinction between these two processes, let the one be called neurosis and the other psychosis."

Von Feuchtersleben used the latter word in its present psychiatric significance in his "Lehrbuch der Aertzlichen Seelenkunde" in 1845. Its repeated appearance in the first volume of the Allgemeine a Zeitschrift für Psychiatrie in 1844 would strongly suggest a frequent use of the term in the German psychiatry of that day. It was unknown in English works until quite recently, although the word is found in Maudsley's "Responsibility in Mental Diseases" (1874)—"No wonder that the criminal psychosis which is the mental side of the neurosis, is for the most part an intractable malady, punishment being of no avail to produce reformation." Lewes, in "The Problems of Life and Mind" published after his death in 1879, makes a very significant remark: "Pathologists call it a psychosis, as if it were a lesion of the unknown psyche." Clouston's 1911 edition makes no reference to psychoneuroses as such.

The word neurosis has been much more extensively employed in medical literature. William Cullen, a well-known professor in the University of Edinburgh, in his "First Lines of the Practice of Physic" in 1774, said: "I propose to comprehend, under the title of neuroses, all those preternatural affections of sense or motion which are without pyrexia, as a part of the primary disease." In his "Synopsis Nosologicae Medicae" in 1785 he divided diseases into four general classes: Pyrexia or febrile diseases; neuroses or nervous diseases, as epilepsy; cachexiae or diseases resulting from bad habit of the body, as scurvy; and locales, or local disease, as cancer. Brachet,[333] who was one of the earlier writers on the subject of hysteria, defined that disease in the following words in 1847: "Hysteria is a neurosis of the cerebral nervous system, which manifests itself more or less brusquely by crises of general chronic convulsions and by the sensation of a globe ascending in the course of the oesophagus, at the upper extremity of which it becomes fixed, causing there a menace of suffocation." Briquet, another French writer, expressed somewhat similar views in 1859. The word neurosis as now used may be said to refer to a functional disturbance of the nervous system, which, if directly due to etiological mental factors, is spoken of as a psychoneuroses.

Just what diseases are to be included under the grouping of neuroses and psychoneuroses is another question. Practically all of the older authorities, at least, have agreed on hysteria and neurasthenia. When we get beyond this point, however, there are wide differences of opinion. Oppenheim, in his second edition, under the heading of neuroses, included hysteria, hypnotism and hypnosis, neurasthenia, morbid fears, imperative ideas, astasia-abasia, traumatic neuroses, hemicrania, headache, vertigo, epilepsy, eclampsia, chorea minor, Huntington's disease, paralysis agitans and many other conditions.

Krafft-Ebing[334] was responsible for the following delimitation of the psychoneuroses, which he admits to be "somewhat dogmatic" and has used for many years largely for didactic purposes: "1. Parasitic, accidentally acquired diseases in individuals whose cerebral functions were previously normal and whose disease could not be foreseen. 2. Disease based upon temporary disposition (grave physical disease and the simultaneous action of powerful exciting causes), hereditary predisposition not excluded, but only latently present in the brain of one easily affected, but previously normal in its functions. 3. Tendency to cure of the disease and infrequency of relapses. 4. Slight tendency to transmission to descendants, and when it occurs, in benign forms (psychoneuroses). 5. Typic course of the disease picture. Mania, as a rule, arises from a melancholic initial stage; and so-called secondary conditions are the terminations of primary conditions. The disease picture, even when it appears, has a certain duration and independence. The whole course of the disease is quite narrowly limited in time, and goes on either to recovery or dementia. 6. No tendency to periodicity of the attacks or the grouping of symptoms. 7. Sanity and insanity are sharply defined, and in striking contrast." In this group he includes mania, melancholia, acute curable dementia and primary hallucinatory delirium. He describes hysteria, neurasthenia, etc., under the psychic degenerations with paranoia and speaks of them as constitutional neuroses. His psychoneuroses certainly do not come within the general acceptation of the term at this time but represent the views of a certain school of German writers.