Outlines of psychiatry

Front matter

CORNELL

UNIVERSITY

LIBRARY

Foreword

In putting forth this little work it is not expected that it will take the place of the larger text-books. No claim whatever is made for exhaustiveness, completeness or originality — it is merely intended to afford a helpful guide to my students, so that they can follow my lectures more easily and more satisfactorily. I have endeavored to describe in a manner as clearly as possible and in a way to be easily understood by the students the principal types of mental disorder, especially with a view of providing the young physician just entering on practice with a working knowledge of the subject. To these descriptions I have prefaced a short account of the nature of the human mind and the fundamental psychological processes for the purpose of providing a proper foundation for what follows and also to place the student in possession of certain general facts so that he will be better able to orient what he may observe.

In arranging the work the first consideration has been the convenience of the student. Important words are italicized and these words occurring in the index can thus be readily found by reference to the page, while the student will find it easier to skim over the pages rapidly and pick out just what he wants. While current literature on insanity has been freely consulted, references and foot-notes have been avoided so as not to detract in any way from the continuity of the text, and the incorporation of extended case histories has also been avoided for the same reason.

I wish here to acknowledge my indebtedness to Dr. Shepherd Ivory Franz for the preparation of the substance of Chapter VII, and to Dr. Smith Ely Jelliffe for many valuable

IV OUTUNES OF PSYCHIATRY.

suggestions, while I desire also to record my thanks to the several members of the medical staff for assistance in supplying case histories, stenograms, and in many other ways.

W. A. W.

Government Hospital for the Insane, .Washington, D. C, June IS, 1907.

Contents

PAGE.

Foreword iii

Chapter I. Psychological Introduction i

II. Definition of Insanity 8

III. Classification of Mental Disorders i6

IV. Causes of Mental Disorders 21

V. Treatment 29

VI. General Symptomology '^M

VII. Examination of the Insane 65

VIII. Paranoia and Paranoid States 94

IX. Manic-Depressive Psychoses 108

X. Paresis 124

XI. Dementia Precox 142

XII. Involution Melancholia 163

XIII. The Senile Psychoses 171

XIV. The Infection-Exhaustion Psychoses 181

XV. The Toxic Psychoses 187

XVI. Psychoses Associated with other Diseases 205

XVII. Borderland and Episodic States 216

XVIII. Idiocy and Imbecility 222

CHAPTER I.

PSYCHOLOGICAL INTRODUCTION.

Insanity has been defined as an absence of sanity. This is rather an evasion than a definition. The difficulty is simply once removed and it becomes necessary to define sanity. An attempt to do this would demonstrate much the same difficulties that we had when attempting to define insanity. However, a material advance towards both ends, or at least towards understanding both conditions can, I think, be made by describing briefly ' the fundamental processes of the normal mind. Before doing this, however, a few preliminary considerations are necessary.

The body is made up of a great number of organs each one of which has a definite purpose : The kidney to secrete urine, the lungs to carry on respiration, the heart to force blood through the vessels, the stomach and intestines to digest and absorb nutrient. Definite as is the function of each of these organs its action must be timed in response to certain conditions and in relation to the other organs of the body or it does not serve its purpose in the individual economy. The stomach must secrete its juices when food is introduced, the bladder contract when there is urine to be expelled, the active brain must be supplied with an increased amount of blood, the kidneys and the skin must act harmoniously together to excrete certain substances, the respirations increase on physical exertion and so on indefinitely. Now it is the duty of the nervous system to see that the functions of the several organs are rightly timed and properly adjusted in relation to one another. This is the function of the lower nerve centers.

The highest nerve centers of the cerebral cortex that constitute the physical basis of mind have quite a different function. Their duty is to so regulate and control the actions of the individual as to best serve his interests in his relations with his environment.

In order to do this the mind must obtain knowledge of the environment through the sense organs, assimilate this knowledge, and then act in accordance with it. To illustrate: A man standing in the middle of the street sees a runaway team dashing towards him. His sense organs take the information to his mind of the presence of the runaway team, its distance from him, the distance to the sidewalk from where he stands and many other things. His mind assimilates all these facts and by a process of reasoning reaches the conclusion that safety lies in his immediately gaining the sidewalk which is in front of him. The necessary volitional processes are initiated and thus the actions of the individual are so related to the conditions in his environment as to conserve his best interests: in this case to save his life.

In order that the adjustment of the individual to his environment could take place three things were necessary : ( i ) A knowledge of the environment must be gained. (2) This knowledge must be associated and brought into relation with previous experiences. (3) It must be transformed into the appropriate actions. The sensorium subserves the first of these functions, the intellect the second, and the motorium the third. The function of the sensorium is perception, of the intellect thinking, and of the motorium volition. (See Fig. i.)

With this broad view of the function of consciousness to guide us we may now describe the separate processes more in detail.

As we have seen all our information of the environment must come through our sense organs it follows of necessity that sensations play an important part in making up the con-

PSYCHOLOGICAL INTRODUCTION. 3

tent of (Consciousness. These sensations are the result of the stimulation of the sensory nerves, usually their terminals in the specialized end organs, and in the last analysis comprise the unanalyzable material out of which consciousness is composed much as the atom in the Daltonic conception of matter

SENSOR I UM

PCnCEPTION

INTCLLECT THINKING

MOrORIUM VOLI TION f iG. I. a, o'j c?, a', o', represents the afferent peripheral nervous system, the avenues for conveying sensory impulses inward to the mind. s, ^, ^, ^, z*, represent the efferent peripheral nervous system, the avenues through which motor responses travel.

was supposed to be the unanalyzable unit which by combination with others both similar and dissimilar went to form masses of matter as we know them. So the eye gives us sensations of light of different colors and intensities, the ear sensations of sound of varying qualities and loudness and so on in each sensory realm the sensations received being variable both qualitatively and quantitatively.

If we will stop and consider for a moment, however, we will see at once that these elemental sense experiences, like atoms, cannot exist alone and uncombined : That sensations of light, sound, pain, coldness, can never as such go to make up a conscious state. In front of me as I write is something which produces the sensation of a variously shaded, round patch of yellow, but even while looking at it I know much more of it than simply that it is a patch of yellow: I recognize it as an orange. What has been added to the visual sensations of roundness and yellowness to produce this result? Just this. Many times in the past have I had the same sort of sensations of roundness and yellowness impressed on my consciousness and many times in connection with these sensations have been others of touch, taste, and smell and to their combination I have in the past given the name orange. So now when the sensations of roundness and yellowness are received they call up in consciousness those other sensory elements of touch, taste, and smell which have occurred before. The association of the previous with the present sensory elements causes me to recognize the round patch of yellow — ^not solely as a patch of yellow — but as an orange. To this process of forming an image in the mind of an object presented to the senses is given the name perception.

It is this process of perception which furnishes to the individual the knowledge of his environment which by association with the knowledge gained in the past leads to appropriate actions. This process of ass^ociation is an association with ideas which may be said to be images of objects formed in the mind but not presented to the senses at the time. The only difference then between percepts and ideas is the presence in the former of sensory elements.

This process of the relation of percept to ideas and the association of ideas one with another or in general terms this process of the assimilation and rearrangement of the materials of knowledge furnished by the senses with the materials already present in consciousness is the process of thinking. Now when froni the association of two or more ideas there issues forth a new and different idea the process which produces this result is the process of reasoning and the new idea is known as a judgment.

Having received information of the environment by the process of perception and having assimilated the various percepts, reasoned regarding them and reached certain judgments.

PSYCHOLOGICAL INTRODUCTION. S

the next thing in the order of events is the initiating of appropriate actions. If the reasoning is at all complicated there are usually several judgments formed, each one of which may tend to express itself in an appropriate action, the strongest one finally, however, succeeding in expressing itself. This conflict of tendencies has been described as the "battle of motives " by Ziehen who gives the following illustration :

" I see a rose in a strange garden (stimulus and sensation). A long series of ideas is aroused by the stimulus and the visual sensation of the flower (idea-association). For instance, the memory of the rose's fragrance comes to mind, then I think how well it would look in my room, that it is the property of another, that plucking it would be punishable, and so on. Only after the whole series of presentations has passed before the mind does action follow, and whether I pluck the flower or go my way without it will depend upon the strength and intensity of the conquering idea."

The conscious realization in action of the strongest motive is the process of volition and is accomplished by a feeling of freedom to choose which motive shall dominate. The sum total of the actions of the individual is known as conduct.

All of these various processes which have been described must of course be conceived of as taking place in conjunction with certain physiological processes in the cells, and fibers of the highest nerve centers. These physiological processes, here as elsewhere, involve changes in the energy and the material substance of cells and fibers and so when a certain mental process has occurred once accompanied by its correlative physiological process the changes in nerve cells and fibers will have left such an impress that a subsequent process of this sort will occur more readily. In other words a mental process having once occurred tends to recur in the same way when the same conditions are repeated. This tendency is the physiological basis of memory, which psychologically may be said to be the recurrence to consciousness of a previous experience and the recognition of it as having occurred before.

All mental processes, besides these special qualities which characterize them, are accompanied by certain general conditions of consciousness known as affects which are pleasant or unpleasant, pleasurable or painful, agreeable or disagreeable, and like sensations are unanalyzable, elemental, constituents of consciousness. These pleasurable or painful conscious states arise as the result of the interaction between the individual and the environment and are known as feelings when this interaction is relatively simple and direct, i. e., a shrill whistle may be accompanied by a feeling that is disagreeable to the point of being actually painful. When the interaction is relatively more complex and indirect there may result the state of consciousness known as an emotion, i. e., the bell of a locomotive and the hiss of an air brake is heard coupled with screams and cries of pain. The mind at once pictures to itself an accident and the emotion of fear arises in consciousness. If the interaction is still more complex and indirect sentiments arise such as honor, patriotism, etc.

From this description of the processes of the mind it will be seen that they are most intimately connected, in fact that they are not separate and distinct in any sense, but only parts of a large whole. The old psychology conceived of mind as composed of a number of cubby holes in each one of which was pigeon-holed a special faculty, feeling, thinking, volition, each one of which was quite as distinct from the others as this illustration implies. Now, however, all that is changed. The " faculty concepts " are conceived of as what they really are, " class designations of certain departments of the inner experience," and not " forces, by whose means the various phenomena are produced." " Objectively, we can regard the individual mental processes only as inseparable elements of interconnected wholes." Mental processes, from their incidence in sensations to the release of the motor responses constituting conduct are conceived to have as their physical substratum a continuous neural process. The process, although differently named in different parts of its course for convenience of designation, is a continuous one.

Chapter II. Definition Of Insanity

In discussing a subject, especially if there be some question as to its nature, it is natural that the first consideration should be given to defining it. A definition, to be a perfect one, should include everything that the term defined is applicable to and exclude everything to which the term is not applicable. Innumerable attempts to frame a definition of this sort of insanity have been made by eminent alienists all over the world but up to the present time it can not be said that there is a satisfactory definition of insanity in existence. And after all it is not strange that this should be the state of affairs. Mind is a function of the highest nerve centers of the brain, and the brain is the most complex development of organic evolution. It does not seem strange therefore that the disorders of this complex should not be reducible to the simplicity of a definition.

Notwithstanding our inability to define insanity, however, it often becomes desirable to designate what insanity is as accurately as possible in a few words. A definition is not infrequently asked for in court and it is necessary for the physician to have one ready at hand, always, however, fully appreciating its limitations. For this purpose there are several short definitions which are good. Some of the best are the following :

That mental condition characterized by a prolonged change in the usual manner of thinking, acting, and feeling, the result of disease or mental degeneration (Chapin).

Insanity is a manifestation in language or conduct of disease or defect of the brain (Peterson).

A cerebral affection, ordinarily chronic, without fever, characterized by disorders of the sensibility, of the intelligence, and of the will (Esquirol).

o OUTLINES OF PSYCHIATRY.

Insanity is a special disease, a form of alienation characterized by the accidental, unconscious, and more or less permanent disturbance of the reason (Regis).

Insanity is a more or less permanent disease or derangement of the brain producing disordered action of the mind in such a way as to put the subject in a condition varying from his normal self and out of relation with his environment (Brower and Bannister).

Insanity is a serious alteration in the psychical functions of the brain. This leads to such departure from the normal in speech and conduct that the patient can no longer adapt himself sufficiently to his environment (Dana).

Insanity is a symptom of perverted function or of disease of the brain that impairs or destroys mental integrity (Eskridge).

All of these definitions have their good points as well as their defects. Perhaps by combining the good points and eliminating the bad we could hope to reach a definition somewhat more, although of course not altogether, satisfactory.

The word insanity is applied with reference to the mind, not with reference to the organ affected or the disturbance in that organ, whatever it may be. The word is used to denote a condition of the function mind and not of the organ brain. We may then start our definition by saying that insanity is a disorder of the mind. Mind, however, as we have already had reason to assume, must be conceived of as being the expression of a neural process, and a disorder of mind cannot be conceived of without postulating a disturbance in this neural process. If then, for the purpose of this definition, we use the word disease to indicate such a disturbance in the neural process, and the word brain to apply to the physical substratum of mind then we may amplify our definition by adding due to disease of the brain.

The use of the word disease here is, I am aware, somewhat broader than usual. It is, however, desirable to make the wording of a definition simple, avoiding as far as possible explanatory or abstruse phrases. Disease ordinarily refers to

DEFINITION OF INSANITY. 9

a process producing tissue changes. While many of the forms of insanity are due to such a condition in the brain there are others that present no demonstrable lesion or in fact are due to disease of some other organ. For instance, nephritis may cause uraemia, which in time may produce a psychosis due to the poisoning of the brain by the products of faulty tissue metabolism. Here the patient would hardly be thought of as suffering from a disease of the brain, but rather from a disease of the kidneys. The insanity is entirely a secondary affair. We cannot doubt, however, that there is a disturbance of the neural processes underlying the phenomena of mind. Quite likely these disturbances are too minute to result in demonstrable tissue changes, perhaps they may be chemical in nature, they are nevertheless as real as though they were on a larger scale, and it seems to me that such alterations can properly come under the connotation of the word disease. Further than this the conception of insanity as due to disease of the brain is entirely in harmony with modern ideas of the relation of the mind to the brain and with modem brain pathology which is constantly narrowing the group of insanities without demonstrable changes in the brain.

To be more specific. Of what does this disorder consist? It must consist of disorders of some or all of the mental processes already described. The fundamental processes of mind disorder of which produces insanity are thinking, feeling and acting. Disturbance of the process of receiving information from the environment cannot of itself constitute insanity. Thus blindness, whether peripheral or central in origin, simply makes it impossible for the individual to receive certain kinds of sensory experiences, it does not produce a disorder of the mind.

The elementary materials of knowledge are brought in from the sense organs by the afferent nerves. Disturbances in the sense organs and nerves leading from them can therefore only result in a change in the character of this material brought to the mind and cannot in any way be symptoms of its disorder.

lO OUTLINES OF PSYCHIATRY.

Simple sensations, however, practically never occur without some element of perception and these simple perceptions stand at one end of a series, the other end of which is constituted of the most complex intellectual operations.

Although I have designated perception as the function of the sensorium yet this does not strictly conform to the facts in the case and was rendered necessary because of the limitations of language in an attempt to classify the mental processes in an easily intelligible way. As soon as one attempts to split things up in nature into distinct and clearly defined subdivisions we must compromise somewhere, because such clean-cut divisions do not exist, but as in this case are constructed purely for convenience.

The process of perception, as long as it was involved solely in associating present with past sensations, might be said to be purely a function of the sensorium, but as was said above pure, elementary sensations practically never occur, so that perception always involves association with previous mental states, feelings, ideas, and when as a result the round, yellow patch of color in front of me is perceived to be an orange such complicated mental processes are involved as recognition, classifying, naming. The processes are all processes of assimilation, combination, and rearrangement of the materials of knowledge, and as such are functions of the intellect. It is for these reasons that disorders of perception are not included in the definition of insanity, for when they occur they involve disorders of thinking. The mind must be disordered before the materials of knowledge brought in from the sense organs by the afferent nerves can be so combined as to produce symptoms of insanity. The most characteristic disorders of perception, hallucinations, probably never occur primarily as evidence of mental disease, but only secondarily as a result of disorder of the central receiving apparatus.

Disorders of memory also cannot alone constitute insanity. These disorders are in the main disorders of impressibility and of retentiveness, but impressibility and retentiveness in reality

DEFINITION OF INSANITY. II

are conditions of the physical substratum underlying the manifestations of memory. The mere fact that this nervous substratum is impressed more or less deeply and permanently by a process occurring within it does not in any way involve the nature of the special process under consideration. Thus disorder of memory alone, unaccompanied by other symptoms of the disorder on which it depends or by secondary symptoms growing out of it, quite contrary to the popular belief, cannot constitute insanity, although it is frequently found as an intimate part of the clinical picture.

Disturbances in the processes of thinking, feeling, and acting we may expect to find in every case. In the old "pigeon hole " psychology with its many " faculties " we might expect to find disorders of the most circumscribed kind. Now, however, we conceive the neural process underlying mind to be continuous. Any disturbance which produces insanity is a disturbance of this process, and the process as a whole must suffer from a disturbance of any part of its course. Of course the amount of the disturbance may be variously distributed so that the brunt may fall here or there, but feeling, thinking and acting may be expected all to show some trace of disorder if examined into carefully, although it may appear that only one is affected. For instance, paranoia was long thought to show only intellectual and perhaps volitional disturbance. We now know, however, that disturbances of feeling are among the most prominent of its early symptoms.

What is the nature of this disorder of thinking, feeling, and acting which constitutes insanity? The use of the word insanity presupposes the existence of a previous state of sanity. Now sanity may not by any means be a normal condition. There are all sorts of mental states of idiocy, idio-imbecility, imbecility, and feeble-mindedness that are far from normal, but they are conditions which for the individual in question are sane. In drawing a distinction between dementia and idiocy, Esquirol well said: "The demented man is deprived of the good that he formerly enjoyed; he is a rich man become poor;

the idiot has always lived in misfortune and poverty." The idiot, the imbecile, the feeble-minded lack something; the insane are suffering from a disorder of that which they possess. We thus may find all sorts of mental conditions which are sane for the individual, and as we have no normal standard of comparison for all people, the best we can do is to compare the individual with his own normal standard, with his condition previous to the onset of disorder; in other words, with the state of mind that has been normal, habitual, usual with him.

Reviewing all the conclusions thus far reached adds to our definition so that it reads now: Insanity is a disorder of the mind due to disease of the brain manifesting itself by a more or less prolonged departure from the individual's u,suat manner of thinking, feeling, and acting.

Having indicated thus far, in a general way, what insanity is; what it is due to; what the processes involved are; and the nature of their involvement, there remains but one further feature that I believe a definition of insanity should contain.

In my description of the functions of the brain I showed that in general the function of the brain is to subserve the adjustment of the individual to his environment. Of course in general such an adjustment constitutes life itself, which as defined by Spencer is " the continuous adjustment of internal relations to external relations." But whereas the lower nerve centers subserve the adjustment of the various organs with one another and with external conditions, the higher centers, the physical substratum of mind, subserve the adjustment of the individual as a whole to external conditions. It therefore follows that the most full and complete mental life is that which adjusts the individual most completely to the conditions of his environment: the best mind, that which is capable of the greatest latitude of adjustment, that enables the possessor to fill any position in life in which he may be placed. And conversely, the poor mind, the narrow mind, permits only a limited adjustment, either limited in the particular position of life occupied by the individual or limited as to its possibilities

DEFINITION OF INSANITY. 13

of scope, or both. The mental life is carried on within relatively narrow limits.

Whatever may be the limits of adjustability for the individual any disorder of the mental processes must necessarily interfere with it. But as we have seen, in discussing the nature of this disorder that we had no absolute standard of comparison but were forced to compare the individual's present condition with his condition in the past, with his usual condition, so here all degrees of adjustability are found in different people and the most limited may, for the individual concerned, be normal. The interference with the adjustment of the individual with his environment is therefore a disorder in so far as it is a departure from his previous, his usual condition.

From, the standpoint of disordered function, insanity is then the expression on the part of the individual of his type of reaction to the conditions of his environment. Insanity cannot be spoken of as a disease any more than hyperchlorhydria ; it is but a symptom^ — a type of reaction, an effort on the part of the individual to meet conditions. It is true that some disease may be at the bottom of this disturbance of adjustment, perhaps a disease of the brain such as paresis renders the reactions of the individual inadequate, for we must remember that the brain is just as truly a part of the environment of the mind as the rest of the body, or in fact as anything even outside of the body.

The complete definition of insanity would then read : Insanity is a disorder of the mind due to disease of the brain manifesting itself by a more or less prolonged departure from, the individual's usual manner of thinking, feeling, and acting, and resulting in a lessened capacity for adaptation to the environment.

As I have intimated all along a perfect definition of insanity is impossible because our knowledge of the subject to be definefd is not complete. As our knowledge increases our ideas must constantly change and definitions can be but the crystallized product, as it were, of our ideas at any one time. We can see already how far we have advanced from the time of Esquirol, who emphasized in his definition that insanity was a cerebral affection " without :fever."

Aside from these considerations we found that the definition, had to be at best a compromise. To clearly define a subject, to put a fence about it, as it were, is impossible, when as a matter of fact that subject merges into the adjacent territory at all points. We found, for instance, that there was no standard of comparison that could be called sanity, deviations from which constitute insanity, and again, even in the use of language difficulties arose and the word disease had to be broadened in its scope of application, while the term perception was seen to stand for a process so indefinite in its limitations as to result in serious embarrassment in its use.

The definition finally reached is, I fully realize, imperfect and at best a compromise, and I am aware that it does not greatly differ, especially in parts, from the definitions already in existence. I have endeavored, however, to make the wording of it somewhat more exact and its synthesis, I trust, may prove a suggestive review in a few words of the nature of insanity in the light of our present knowledge.