Psychological medicine; a manual on mental diseases for practitioners and students

Front matter

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A MANUAL ON MENTAL DISEASES FOR PRACTITIONERS AND STUDENTS

BY

Preface

TO

THE FIRST EDITION

The object of this book is to lay before the student a short account of the principles and practice of Psychological Medicine. Several years of teaching have fully convinced me that for his future usefulness the student must bethorough.lv taught the underlying principles of disease, whether that disease falls within the province of Medicine or Surgery. It is not sufficient to know that certain sjmiptoms will be found to exist in certain maladies ; the cause of their presence and their relative importance are subjects requiring intelligent study.

The keen and thoughtful observer will succeed in healing disease when a superficial physician fails, although the latter may have a thorough knowledge of his bookwork. Once the fundamental principles of insanity have been learnt, the disorders of mind will at least be intelligible, and no longer a mere concatenation of strange symptoms.

Throughout the following pages the student will be constantly reminded to look upon mental disorders in the same way that he views disease in general. This warning is very necessary, as so many men regard the insane as if they were the victims of some strange visitation, and not sufferers from ordinary illness.

Antiquated terms, such as ' mad ' and ' lunatic,' are strongly condemned, and are never used in this book, except when quoting Acts of Parliament or legal authorities. The retention of these words is harmful in many ways, and retards progress. It is therefore incumbent on the physician not only to discontinue using them himself, but to discountenance the employment of them by others.

Vlii PEEFACE

I have not cited cases illustrative of the various disorders : to have done so would have made the book more cumbrous, with no commensurate advantage. The description of isolated cases may be very misleading, disorders being largely coloured by the individual characteristics of the patient.

I have also decided not to reproduce photographs of patients suffering from the various diseases. In the majority of instances it is impossible to give a typical photograph of a sufferer from any disease until that disease is confirmed. The earliest symptoms of mental disorders rarely, if ever, show themselves by changes in the facial expression or attitude of a patient. Photographs, therefoie, do not assist the diagnosis of mental disorders in their earliest forms, the point upon which I desire to lay especial stress. It is during the initial stages that disease lends itself most readily to treatment. Unfortunately, the early symptoms of mental disorder are commonly overlooked, as frequently neither the physician nor the laity attach sufficient importance to slight changes of character or symptoms of nervous fatigue. The question of treating minor symptoms, such as restlessness and irritability, is a point to which the reader should give attention.

As regards the general scheme of the book, an attempt has been made to meet the requirements both of the general practitioner and of the student.

The opening chapter is devoted to a short description of normal psychology, as it is difficult for a physician to investigate or accurately gauge symptoms of the diseased mind if he is totally ignorant of normal mental processes.

No new classification of insanity is offered, but I have endeavoured to hold an even balance between the old and the new school of Psychiatry. If we cannot accept the whole of Kraepelin's classification of mental disease, we can by no means ignore it, forming as it does the most important contribution of recent years to the literature of insanity. I do not disguise from myself the many imperfections of my attempt at readjustment, but crave the clemency of the critics on the ground that the remodelling of old ideas is ever difficult.

A chapter has been devoted to the subject of law in its

PREFACE ix

relationship to insanity, and matters such as testamentary capacity and criminal responsibility have been especially dealt with.

As sleeplessness is both a frequent cause of, and an important symptom in, most forms of mental disorder, a chapter has been reserved for its consideration.

The subject-matter throughout the book has been broken up into sections for the benefit of those who wish to refer to special matters only.

This book is designedly simple in both arrangement and language, and is, to a great extent, a summary of many years' asylum experience digested for the student. If it in any way helps the student to a better understanding of insanity, or assists the general practitioner in the early diagnosis and treatment of mental disorder, it will have fulfilled its purpose.

I owe my gratitude to many friends, who have given me invaluable assistance. To Dr. P. W. Mott, Director of the Laboratory and Pathologist to the London County Asylums. I am deeply indebted for supplying me with most of the illustrations found in this book ; and also for his many kind suggestions and ever ready help. I accord my thanks to the members of the Asylums Committee of the London County Council for their kindness in allowing me to reproduce several illustrations from the ' Archives of Neurology.' I am also under no small obligation to my friend and former colleague, Dr. E. Goodall, Medical Superintendent of the Joint Counties x\sylum, Carmarthen, not only for the loan of several photomicrographs, but also for his kindly assistance in the reading of a large i^ortion of the manuscript, and for many useful suggestions and corrections. To my brother, Norman Craig, barrister-at-law, I am indebted more than I can well express for devoting much time and thought to the revision and correction of the whole manuscript. I also owe my grateful thanks to my colleague, Dr. Stoddart, for several kind suggestions, and to Dr. J. S. Bolton and Dr. G. Watson for the very kind loan of microscopic preparations and photomicrographs.

M. C.

March 1905.

CONTEXTS fHAP. PACE

Preface v

I. Normal Psychology 1

II. What is Insanity ? .18

III. Causation of Insanity 2.3

IV. Classification of Insanity .38

V. General Symptomatology 45

VI. Manlv 99

VII. Melancholia and States of Depression . . . . 116

VIII. Stupor 134

Catatonh. 139

IX. Chronic Delusional Insanity (Paranoia) . . . 142

XL Secondary Dementia .167

XII. Epochal Insanities —

Climacteric Insanity' 182

Senile Insanity and AeteriopathicJDemextia . . 187

XIII. Intoxication Psychoses — ■

Korsakow's Disease 214

Morphinism ... ... .215

Cocainism 219

Plumbism 221

XIV. General Paralysis of the Insane (Dementia Paralytica) 223

XV. Exhaustion Psychoses- Nerve Exhaustion and Neurasthenia . . . 259 Acute Hallucinatory Insanity 265

XU CONTENTS

CHAP. PAGE

XVI. General Neuroses— xvii. psychasthenll and obsessions . . . . . . 298

XVIII. Insanity and Physical Diseases —

Phthisis and Insanity 305

Diabetes and Insanity 308

Influenza and Insanity 309

Chorea and Insanity .311

Insanity of Myxedema 314

Exophthalmic Goitre .317

Cretinism . 319

Gout and Insanity 322

Rheumatic Fever and Insanity 323

Heart Disease and Insanity 324

Sunstroke and Insanity 325

Malaria and Insanity 325

XIX. Defective Mental Development —

XX. Feigned Insanity 363

XXI. The Relationship of Insanity with Law . . . . 370

XXII. Sleeplessness 390

XXIII. Case-taking 403

XXIV. Treatment 424

INDEX 469

Plates I. and II . between pages 166 and 167

„ III.— XXVII 256 and 257

Chapter I

Although it may be outside the province of a treatise on Mental Diseases to discuss Psychology and Psychological Problems, nevertheless it must be helpful, if not absolutely necessary, for the student to know something of the workings of the normal mind in seeking to understand the mind which is disordered. For this reason a few preliminary pages may be usefully devoted to a brief review of normal mental processes. Mind is composed of processes which are constantly changing, therefore the ' ego ' of one moment is not the ' ego ' of the next. It is this constant and rapid changing that makes the study of mind so difficult. Further, a mental process is purely subjective, whereas processes dealt with by other sciences are largely objective and can form part of the experience of others. Psychical and physical processes are intimately connected, and our study of mind is largely assisted by observing its influences on the body. For centuries philosophers and scientists have from time to time promulgated various theories as to the relation of mind and body. There are the idealists, who make body dependent upon mind ; and the materialists, who postulate that mind is dependent upon matter. But the psychologist of to-day prefers not to dogmatise in either direction, and the theory of psychophysical parallelism is that which is largely held. This theory neither makes mind dependent upon matter, nor the body dependent upon mind, but states that throughout life there is a chain of psychical events which runs parallel to another chain of physical events, and that these chains are in some way connected ; but the theory does not commit itself as to how this connection occurs. The close relationship between mind and body is evident to all observant physicians. There is a mental aspect to all physical disease ; but this mental aspect is too frequently overlooked, with consequent failure to recognise a symptom the treatment of which would tend greatly to the relief of a patient. The mental depression with gout, and the hopefulness of a patient with phthisis, are symptoms which are apparent to the most careless of observers. On the other hand, how frequently we see such a symptom as the irritability of fatigue, so often an indication of the approach of more serious tiouble, either misconstrued or overlooked.

In the same way, if due attention were given to such physical changes as loss of weight and irregularities of the action of the bowels, in unstable individuals, much mental disorder might be averted. For the moment it is enough to impress upon the reader that the mental aspect of the organism cannot be separated from the physical, and that if the symptoms of the one appear to be more urgent than the other, the lesser must not be overlooked.

Sensation. — ' Sensation ' is the term used to express the most elementary of all conscious processes, and is the result of the stimulation of some bodily organ. Sensations are of two kinds, viz. (1) Special sense sensations, (2) Organic sensations. The former are due to stimulation of one of the special sense organs, and the latter are sensations which are derived from the Muscles, Tendons, Articular Surfaces, Alimentary Canal (hunger, thirst, nausea, etc.), and the Circulatory, Eespiratory, and Sexual Organs.

The organic sensations differ from the special sense sensations by being more diffusible and more closely connected with the feelings. They are not so well defined, and tend more quickly to die out of memory. The attributes of sensation are : (1) Quality, (2) Intensity, (3) Duration, and (4) Extent. Quality is the attribute by which we distinguish one sensation from another ; for instance, a colour is always the same colour no matter how intense or for what length of time it lasts. Further, every sensation differs in intensity, and, according to Weber's Law, ' if sensations are to increase in intensity by equal amounts, their stimuli must increase by relatively equal amounts.' That is to say, the intensity of a stimulus must increase by a certain definite amount before any appreciable difference in the sensation can be detected. The other attributes of sensation apply to time and extent, the latter being present only in the cases of sight and touch. The sense of position and movement is largely made up of sensations derived from muscle, tendons and articular surfaces.

Affection. — Affection has been defined by Titchener in his ' Primer of Psychology ' as an ' elementary conscious process which may be set up by the stimulation of any bodily organ.' There are only two affections, (a) Pleasantness, (b) Unpleasantness. To again quote the same author : ' Now, when we have in consciousness a complex process composed of sensations and pleasantness or unpleasantness, and when the affective side strikes us more forcibly than the sense side, we call the total process feeling.'

Affection differs from sensation in several ways. The more we attend to a sensation the clearer it becomes, whereas if we direct our attention to an affection it fades at once. Habituation weakens affection, but not sensation, for we find that after weak sensations have lasted for some time they may even become painful. Affections which have been almost unbearable, in course of time, if they continue, may be scarcely noticed ; this is especially noticeable in disorders such as melancholia. Both with feeling and affection there are certain bodily changes which accompany them. They are not so marked as the changes found with emotion, but consist of alteration in the state of pulse, breathing, bodily volume, and muscular strength. These changes clearly show the close relationship between mental and physical processes.

Attention. — Attention is the sustained and continued concentration of the mental faculties on some particular object or idea. Mental processes do not all flow along at the same level ; some we encourage, others we endeavour to inhibit. Thus attention consists partly of reinforcement and partly of inhibition. The perceptions which we encourage become clearer, last longer, and are more useful. Among the bodily aspects of attention we find that the muscles, especially of

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the neck and eyeballs, are fixed, expiration is prolonged, or the breath may be held altogether. The head is often turned to one side and fixed. Probably the tension of the tendons and muscles in action largely accounts for the sensation of effort (Conation) which is occasioned by active attention. Attention is constantly fluctuating, and cannot be fixed for more than a short time together. The range of attention varies, and although probably one cannot concentrate the mind on more than one complex idea at a time, one can, as has been shown by experiment, attend to several simple stimuli at the same moment.

In addition to active attention there is a state of passive attention, or at times spoken of as instinctive attention. Certain things have to be attended to, whether one wishes it or not ; for instance, loud sounds or bright lights. One is largely indebted to passive attention for warning of any sudden danger. Attention is an attribute of fairly late development. Some children never acquire it, and at all times it is easily lost ; attention fails with fatigue, and is affected in all forms of mental disorder. Attention is the basis of action, for in the primitive organism without attention there would be total inaction.

Conation. — Closely connected with Attention is found a condition known as Conation, or Feeling of Effort. All consciousness is more or less conative, but some states of consciousness are far more conative than others. In prolonged active attention there is a strong feeling of effort. Some authorities believe conation to be central in origin, and directly due to brain activity ; others hold that it is purely the result of tension and strain in the muscles and joints, and is thus produced by peripheral changes.

Perceptions and Ideas. — By origin perceptions and ideas are alike ; but, for the sake of clearness, a distinction between them may be drawn. Perception may be spoken of when sensation is actually aroused by the presence of some external stimulus ; idea, when the mental image of a former sensation is intended. For instance, I see a book in front of me : that is a percept ; while if I close my eyes I have a mental record of the former sensation derived from seeing the book : that is an idea.

Perceptions and Ideas are divided into three classes, viz. (1) Qualitative, (2) Extensive, and (3) Temporal. What has been said of sensations can be said of perceptions, so far as quality is concerned. Further, one is aware of locality and position ; one recognises a definite arrangement of things in space. This knowledge in early life is largely acquired from tactual sensation ; a child will stretch out its hand to reach things far beyond its grasp. As evolution goes on, the visual sense develops, and in adult life it is on this sense that chief reliance is placed for information as to size, position, and distance. Binocular vision is far more accurate in measuring the third dimension than monocular vision. There is no inborn sense of the position of things in space ; it is derived from education, and by such data as the size of the object, its outline and distinctness, the uniformity of colouring, by the accommodation and movement of the eyes, and by comparison with surrounding objects.

Rhythm. — Temporal perceptions and ideas include rhythm. Now rhythm is found to accompany both mental and physical processes. Sleeping and waking occur, or ought to occur, at regular intervals. Walking is rhythmical. Marked periodicity is present in the reproductive functions, especially in those of the female. Allusion has already been made to the fact that attention waxes and wanes : it does so in a rhythmical manner. The aesthetic sentiment is found to favour rhythm, as is shown by melody and dancing. Ehythm also plays a prominent part in many forms of mental disorder. The insanity known as folie circulaire is markedly rhythmical. Dipsomania and other impulsive forms of mental disease may be periodical in onset. There are several disturbances of the process of perception, such as Illusions and Hallucinations, but it will be more convenient to describe them in a subsequent chapter.

Association of Ideas. — Let consideration next be given to Association of Ideas ; that is to say, the tendency of every idea to bring into the mind its associated ideas. This may occur by simultaneous association ; a presented idea may bring up without any appreciable delay another idea. Or the association may be successive, as instanced by reverie or train of thoughts.

The association of ideas plays a far larger role in an individual's life than many persons appreciate. If it were not for this process we should never get beyond the most rudimentary state of thought and action. This power of association is the basis of habit, and habit directs and dominates our whole life.

Habit. — Habit, as already stated, is an example of the law of association. Broadly speaking, there are two great divisions of habits : (1) Those which are inborn in us, and which may be looked upon as instincts ; (2) Those which have been acquired in the lifetime of the individual. It is over the latter that we have the greatest control. Professor James states, ' The phenomena of habit in living beings are due to the plasticity of the organic materials of which our bodies are composed. Our nervous system grows to the mode in which it has been exercised. Habit simplifies the movements to achieve a given result, makes them more accurate, and diminishes fatigue.' Watch, for instance, the beginner learning to play the piano ; at first the energy employed seems to spread all over the body, but the more easily the special movement occurs, the slighter the stimulus required to produce it ; and, the slighter the stimulus, the more its effect is confined to the fingers alone. Dr. Maudsley puts the matter very tersely when he says, ' If an act becomes no easier after being done several times, if the careful direction of consciousness were necessary to its accomplishment on each occasion, it is evident that the whole activity of a lifetime might be confined to one or two deeds — that no progress could take place in development — a man might be occupied all day in dressing and undressing himself ; the attitude of his body would absorb all his attention and energy ; the washing of his hands or the fastening of a button would be as difficult to him on each occasion as to the child on its first trial, and he would furthermore be exhausted by his exertions.' Again : ' Habit diminishes the conscious attention with which our acts are performed.' We automatically learn to do the right thing at the right moment, as in walking, jumping, fencing, etc., but we may also learn to do the wrong things habitually !

Once again, to quote Professor James, ' We all of us have a definite routine manner of performing certain daily offices connected with the toilet ; our lower brain centres know the order of these movements, and show their surprise if the objects are altered so as to oblige the movement to be made in a different way. But our higher thought centres know hardly anything about the matter. Few men can tell offhand which sock or shoe they put on first.' I cannot tell the answer, but my hand never makes a mistake. Now in action grown habitual, that which instigates each new muscular contraction to take place in its appointed order is not a thought or a perception, but the sensation occasioned by the muscular contraction just finished (in doing a thing, if one fails one often has to start again at the very beginning) ; a strictly voluntary act has to be guided by idea, perception and volition throughout its whole course. In an habitual action, mere sensation is a sufficient guide, and the upper regions of the brain and mind are set comparatively free. For example, the knitter keeps on with her knitting, even while she reads or is engaged in a conversation.

Habits we must form, so that the importance of forming right ones cannot be over-estimated. Let me remind you once again that we acquire habits by means of actively attending to that which we are learning ; and, having ofttimes accomplished it, the action, mode of thought, or whatever it may be, passes out of the realm of consciousness and becomes automatic. Throughout life we are constantly putting by (packed up, as it were, all ready for use) judgments and actions which for the future will be available for immediate requirements. Thus again you will see how important it is that these bundles of habit should be built carefully up whilst in the conscious stage ; for once they pass beyond this stage they will remain, maybe for many years, as attributes for good or ill.

The importance of habits cannot be over-estimated and in treating mental disorder their significance is constantly compelling attention. Take sleep : it is largely habit, and if confidence be lost and the association between bed and sleep be broken, this may become a serious obstacle to the successful treatment of insomnia. Similarly delusions of persecution may be originated and confirmed by the habit of treating those around us with suspicion. The emotions should be kept under control and any wide sweeps from excitement to depression should be corrected. The physician and those whose work lies in the training of the young should never forget to encourage the development of good habits, and the eradication of bad ones, whether in the matter of physical functions or in the attributes of mind. And, when we turn to disease, it must always be borne in mind that bad habits may seriously jeopardise the chances of recovery and therefore must be corrected, for, as we shall point out later, bad habits may be formed during the illness which will in future militate against the patient's usefulness in life.

Emotions. — Emotions are more complex than feelings. In the former the organic sensations take a prominent place ; so prominent, indeed, that some authorities go so far as to say that organic sensation is the basis of emotion. In emotion the same bodily changes occur as in the case of feeling ; but in addition there are changes in the secretory organs and in the involuntary muscles. The surface of the ho&y may be bathed in perspiration, the mouth may be dry, and the eyes wet with tears. Extreme emotion is spoken of as Passion, and when an emotion has lasted for some time it usually calms down into a mood, which denotes a weaker emotive state. The feelings and the emotions are a useful barometer by which the mental state and even the physical condition of individuals may be judged. Disturbance of the emotions is frequently an early symptom in all forms of disease, whether bodily or mental ; and, in some insanities the symptoms may be chiefly confined to emotional alterations ; or it may be that the affective changes are the concomitants of a more complex insanity.

Sentiment. — A sentiment differs from an emotion in that with the former there is a state of active attention. It is by this means that we judge and say, * This is right or wrong,' ' This is true or false.' Belief and disbelief are common forms of sentiments, and it must not be forgotten that a disbelief is just as positive a state as belief. Doubt is the state of uncertainty which lies between two beliefs. In such a condition as that of folie de doute, which will be considered later, it will be found that the active weighing of motives, and the fear of doing wrong, are the determining factors in the inaction of a fair proportion of the insane. The aesthetic sentiment is one that has no small interest to those who have the treatment of the insane, for it undergoes alteration in most forms of mental disorder. The acute maniac is often decorated to an extravagant extent, and as a rule sees beauty in objects which in sanity he would condemn as vulgar or commonplace. Conversely, the melancholiac will deplore that things which he formerly thought beautiful now appear gloomy and ugly. Untidiness and want of personal cleanliness are characteristics of many of the insane.

Memory. — Memory is so large a subject that it is difficult to condense it into narrow limits ; but it must be here described in as few words as are compatible with clearness. Kulpe defines that which is understood by memory in the following words : ' That an impression which has been produced in the past by a particular stimulus does not disappear outright with the cessation of that stimulus, but is somewhat conserved, and, under certain conditions, has the power of again becoming a noticeable part of conscious contents, without any renewal of the original peripheral stimulation.' In other words, memory means the tendency of the nervous elements to fall into a similar state of commotion to that in which they were when the original stimulus acted upon them. Cognitiori is the direct apprehension of an object, it is association by similarity, one sees an object and at once cognises what it is. Recognition consists of three processes : there is an object before us (Percept) ; and this percept calls up by association other ideas and with this there is a feeling of familiarity.

Memory differs from recognition in that the percept is replaced by an idea. There is no object before us, there is merely the mental image of a former sensation ; otherwise the process is the same, for memory stands in the same relationship to recognition as ideation does to perception. There are many types of memory, varying in different individuals. Memories may be mainly visual, auditory, tactual, or a mixed variety ; other memories consist largely of word-ideas. Mental constitutions vary, and to this fact are due the very diverse ways in which different persons remember things. Two persons may see the same incident, and yet afterwards may describe it in such a manner that it is difficult to conceive that they are relating the same story. This is accounted for when it is remembered that the one may record what he saw, and what especially fell in with his tendencies ; while the other, with tendencies widely different, reproduces the incident from what he heard or from some other standpoint. Thus memory, although not exact, is a partial reproduction, the accuracy of which largely depends on the mental constitution of the individual, and the degree of his attention when the impression was received. Events that created a strong impression, social habits of everyday recurrence, and recent events, are all easily remembered. The power of being able to forget useless things is of great importance in relieving the memory. The marks of a good memory are : (1) The rapidity with which the power of recalling is acquired ; (2) the length of time during which the power of recalling lasts without being refreshed ; (3) the rapidity and accuracy of actual revival ; and (4) the power of forgetting those things which are of no value or have ceased to be of value.

To cultivate a good memory it is necessary to have (1) a keen observation ; (2) a power of concentrating attention ; (3) a method of arranging in a systematic way things to be remembered ; (4) a power of forming association. For practical clinical purposes memory may be divided into two classes — recent, and distant or organised memory. The former is the first to go in amnesic states, as it has a lesser hold on the nervous system.

Imagination. — Imagination is closely allied to memory, and yet differs from it in several important particulars. A memory is more or less a recall or reproduction of a former perception or group of perceptions, whereas imagination is usually derived from a number of former perceptions. Moreover, memory has with it a consciousness that the revival is more or less familiar and has been experienced before. This is not the case with imagination, for with it there is no such feeling of familiarity. Imagination is entirely dependent upon memory for its existence ; for, if the power to recall past experiences be lost, the data necessary for imagination are absent.