Paranoid and Delusional States

patients (6 per cent. of the men, 3 per cent. of the women) spasms or fainting fits had occurred previously in youth, about which it must for the present remain doubtful whether any connection with the psychic disorder may be ascribed to them. Some patients had suffered from chorea. Urstein records seizures in 8 per cent. of the men and in 19 per cent. of the women. In one case I saw the development of a profound catatonia after the existence for many years of undoubted epileptic seizures to which then hysteroid seizures were added. And otherwise hysteroid spasms and paralyses are often observed besides aphonia, singultus, sudden erection, local contractures, and similar phenomena.

The spasmodic phenomena in the musculature of the face and of speech, which often appear, are extremely peculiar disorders. Some of them resemble movements of expression, wrinkling of the forehead, distortion of the corners of the mouth, irregular movements of the tongue and lips, twisting of the eyes, opening them wide, and shutting them tight, in short, those movements which we bring together under the name of making faces or grimacing; they remind one of the corresponding disorders of choreic patients. Nystagmus may also belong to this group. Connected with these are further, smacking and clicking with the tongue, sudden sighing, sniffing, laughing, and clearing the throat. But besides, we observe specially in the lip muscles, fine lightning-like or rhythmical twitchings, which in no way bear the stamp of voluntary movements. The same is the case in the tremor of the muscles of the mouth, which appears sometimes in speaking and which may completely resemble that of paralytics. In a great number of patients I observed distinct twitchings of the musculature of the mouth on tapping the lower branches of the facial nerves. Occasionally one sees uneven muscle-tension on the two sides of the face temporarily or for a longer time, on which Hüfler has laid stress. The out-spread fingers often show fine tremor. Several patients continually carried out peculiar sprawling, irregular, choreiform, outspreading movements, which I think I can best characterise by the expression “athetoid ataxia.”

Aphasia

In two cases it was possible during a state of dull stupor to demonstrate distinct aphasic disorders. The patients were unable to recognise and to name the objects laid in front of them although they could speak and were evidently exerting themselves to give the required information. Repeatedly after long consideration the wrong names came out. The disorder disappeared again after a few hours.

Vasomotor disorders are very wide spread in our patients. Above all one notices cyanosis of the hands, less of the feet, the nose and the ears; from the deep blue colour of the skin, dilated arterial areas are sometimes distinguished as bright red, sharply circumscribed spots, which can be artificially produced by pressure. Further there are found circumscribed areas of oedema, congestion of the head, vivid blushing, dermatography in all degrees, especially in the beginning of states of stupor. Trepsat was able in one case after 48 hours to make the dermatographic writing again visible by light rubbing with the finger-tip; he reports also eruptions and even ulcers of “trophic” origin. The activity of the heart is subjected to great fluctuations; sometimes it is retarded, more frequently it is somewhat accelerated, often also it is weak and irregular; many patients complain of palpitation.

Blood-pressure is as a rule lowered; it fluctuates, however, considerably. Weber found for systolic and diastolic pressure, pulse pressure and pulse frequency low or at most average values especially in stuporous patients. Lugiato and Ohannessian, as well as Lukacs, were able to ascertain frequently a disproportion between blood-pressure and pulse frequency. Bumke and Kehrer observed in plethysmographic experiments in catatonic stupor absence of decrease in volume, as well as of changes in pulse and respiration, on the application of the stimuli of cold and pain, and they point out the relationship of this disorder to the absence of the psychic pupillary reaction.

Respiration is according to d’Ormea’s statements somewhat accelerated and very deep, and it shows many irregularities especially in expiration. Sometimes severe outbursts of perspiration are observed.

The secretion of saliva is frequently increased, usually only temporarily, much seldomer permanently; I was able from one patient to collect in 6 hours 375 ccm. of saliva. The analysis carried out by Rohde in one case gave a specific gravity of 1.0026 and a nitrogen content of 0.1 per cent., values which are at the lower limit of the normal, and do not point to the origin of the flow of saliva by stimulation of the sympathetic. In some patients rumination is observed, especially in the terminal states.

Temperature is usually low, sometimes sub-normal with occasional reversal and small range of the daily fluctuations. Fig. 20. Course of the temperature in the last weeks of life of a patient who was considerably excited and who did not exhibit any apparent bodily ailment. The readings, which had already for more than 3 weeks previously almost always been under 37° C. and on one occasion had sunk to 34.2° C., are repeatedly lower in the evening than in the morning; they sink in the two last weeks of life first to 33.4° C. and then with a single jump rise again to 38.5° C. and even to 39.1° C. towards the end of life.

The menses are usually absent or irregular, according to Pförtner’s statements in two-thirds of the recent cases.

Blood Changes

The obscurity that hangs over the causes of dementia praecox has been a frequent motive for the examination of the blood-picture and of metabolism, but the findings up to now are not very satisfactory. Lundwall found in general no change in the blood, but “blood crises” with decrease in the red and increase in the white corpuscles which appeared periodically. Bruce and Peebles describe in the acute periods of the disease a moderate increase specially of the polynuclears and the large mononuclears, which in stupor, but still more in the terminal stages, gives place to a decrease, specially in the polynuclear leucocytes. Bruce has even made the attempt to establish blood-pictures peculiar to each form of insanity and from them to draw prognostic conclusions, an undertaking, which in face of the many diverse statements must be regarded as premature. Heilemann also reports a small increase of the white blood cells with comparative decrease of the polynuclear forms. Sandri emphasised similar findings especially in catatonic states. Dide and Chenais observed an increase of the eosinophil cells, Pighini and Paoli an increase in the size of the red blood corpuscles with a ring-shaped arrangement of the haemoglobin. Itten was not able to establish any characteristic findings in the blood. However, in some chronic, resistive, demented patients fairly high leucocyte counts were found, and in some dull depressed patients comparatively low counts.

Berger has made the attempt to prove the presence of toxic material in the blood of catatonics by injecting serum of the patients into the occipital lobe of dogs; he found that muscle twitchings, apathy and a tendency to forced attitudes appeared.

Investigations in metabolism have also frequently been carried out. In acute cases Pighini observed increased excretion of nitrogen, phosphorus, and sulphur, of urea, uric acid, and xanthin bases, which he connects with increased breaking down of nucleoproteins containing phosphorus and sulphur. Allers has called attention to the fact that here possibly insufficient nourishment might play an essential part in the states of excitement. During the chronic course, on the contrary, there is said to be retention of phosphorus and nitrogen, and a loss of lime and sulphur. Rosenfeld invariably observed retention of nitrogen, 1-2 grm. daily. A considerable lowering of the need for oxygen which cannot be removed by thyroidin was shown by the researches of Bornstein. The restriction of the oxidation processes which is in healthy persons already noticeable between the 15th and 25th years undergoes here according to his investigations a morbid increase. Graefe also found in catatonic stupor a distinct slowing of metabolism, a lowering of heat production to 39 per cent. of the normal, the increase of oxidation after the intake of nourishment showed a slower development. In the urine of the patients, sugar is occasionally found; it probably is always a case of alimentary glycosuria, which could be fairly frequently demonstrated. Lugiato found retarded excretion of injected levulose. The elimination of methylene blue and iodide of potassium began according to the researches of d’Ormea and Maggiotto considerably later than in healthy persons and lasted longer. In the cerebro-spinal fluid Pighini found in 43 per cent. of his patients cholesterin which he never could demonstrate in healthy persons.

In a series of cases I observed diffuse enlargements of the thyroid gland, occasionally the disappearance of such enlargements immediately before the first appearance of morbid phenomena, also repeated rapid change in the size of the gland during the development of the malady. Occasionally exophthalmos and tremor were present. Lastly we noticed, as the relatives of the patients also did, not infrequently a turgid appearance and a thickening of the skin reminiscent of myxoedema, especially in the face. Unfortunately these findings cannot be made use of further in the meantime because of the frequency of thyroid disease amongst us. Very frequently anaemic and chlorotic conditions appear to be present.

Sleep and Food

During the whole development of the disease the sleep of the patients is frequently disturbed even when they are lying quiet. The taking of food fluctuates from complete refusal to the greatest voracity. The body-weight usually falls at first often to a considerable degree, even to extreme emaciation, in spite of the most abundant nourishment. Later, on the contrary, we see the weight not infrequently rise quickly in the most extraordinary way, so that the patients in a short time acquire an uncommonly well-nourished turgid appearance. Sometimes, in quite short periods, very considerable differences in the body-weight are noticed, probably in connection with fluctuations of the amount of water contained in the tissues. Of the curves which are here reproduced, Fig. 21. shows the body-weight in the usual course of a case of catatonic stupor terminating in dementia of middle grade. Although after the awakening from stupor slight excitement set in, the weight increased very much. Fig. 22. was obtained from the patient whose temperature curve is given above, and who in spite of the most careful nursing and abundant nourishment sank in marasmus of the highest degree without any organic disease. Very great fluctuations of the body-weight, from the initial weight to the double of it, is shown in Fig. 23., which was obtained from a young catatonic. The patient after an initial alternation of stupor and excitement came to us, recovered at first, but then sank with diminution of the body weight again into deep stupor, from which he awoke after some months to increase rapidly in weight to an extraordinary extent; but at the same time the transition to depressive dementia with some features of silly affectation had taken place. Lastly, Fig. 24. shows in a commencing dementia praecox a series of fairly regular fluctuations which kept pace with an alternation of stupor and greater clearness. Later this regularity ceased, and it came to permanent dementia.

CHAPTER V. CLINICAL FORMS

The presentation of clinical details in the large domain of dementia praecox meets with considerable difficulties, because a delimitation of the different clinical pictures can only be accomplished artificially. There is certainly a whole series of phases which frequently return, but between them there are such numerous transitions that in spite of all efforts it appears impossible at present to delimit them sharply and to assign each case without objection to a definite form. We shall be obliged therefore, as in paralysis, to content ourselves at first for the sake of a more lucid presentation with describing the course of certain more frequent forms of the malady without attributing special clinical value to this grouping.

As such forms I have hitherto separated from each other a hebephrenic, a catatonic, and a paranoid group of cases. This classification has been frequently accepted with many modifications, specially concerned with the clinical position of the paranoid diseases, as also by Bleuler in his monograph on schizophrenia; he adds, however, to it the insidious “dementia simplex” as a special form. Racke has made other attempts at classification; he separates out “depressive,” “confused excited,” “stuporous,” “subacute paranoid” forms and a “catatonia in attacks.” Wieg-Wickenthal differentiates “dementia simplex,” “hebephrenia” with pseudomanic behaviour, “depressive paranoid forms” and catatonia.

The undoubted inadequacy of my former classification has led me once more to undertake the attempt to make a more natural grouping, as I have in hand a larger number of possibly more reliable cases. For this purpose there were at my disposal about 500 cases in Heidelberg which had been investigated by myself, in which according to their clinical features, as well as according to the length of the time that had passed, the ultimate issue of the morbid process could be accepted with considerable probability. “Recovered” cases were not taken into account because of the uncertainty of their significance which still exists, but only such cases as had led to profound dementia or to distinctly marked and permanent phenomena of decreased function. On grounds which will be discussed later, it is, as I believe, not to be assumed that by this choice definite clinical types have quite fallen out of the scope of our consideration; at most a certain displacement in the frequency of the individual forms would be conceivable.

The result of this attempt at a classification agrees in many points with the statements of the above-mentioned investigators. First I also think that I should delimit simple insidious dementia as a special clinical form. Next in the series comes hebephrenia in the narrower sense of silly dementia which was first described by Hecker. A third group is composed of the simple depressive or stuporous forms, a fourth of states of depression with delusions. In a fifth form I have brought together the majority of the clinical cases which go along with conditions of greater excitement; one could speak of an agitated dementia praecox. To it is nearly related the sixth form, which includes essentially the catatonia of Kahlbaum, in which peculiar states of excitement are connected with stupor. A more divergent picture is seen in the seventh and eighth groups, in which the cases are placed which run a paranoid course, according to whether they end in the usual terminal states of dementia praecox or in paranoid, relatively hallucinatory, weak-minded-ness. We shall then subject to special consideration the small number of observations, which present the remarkable phenomenon of confusion of speech along with perfect sense and fairly reasonable activity.

Dementia Simplex

Simple insidious dementia as it was described by Diem under the name dementia simplex, consists in an impoverishment and devastation of the whole psychic life which is accomplished quite imperceptibly. The disease begins usually in the years of sexual development, but often the first slight beginnings can be traced back into childhood. On the other hand Pick has also described a “primary progressive dementia of adults,” but it is certainly very doubtful whether it may be grouped with dementia praecox. In our patients a deterioration of mental activity becomes very gradually noticeable. The former good, perhaps distinguished, scholar fails always more conspicuously in tasks which till then he could carry out quite easily, and he is more and more outstripped by his companions. He appears absent-minded, thoughtless, makes incomprehensible mistakes, cannot any longer follow the teaching rightly, does not reach the standard of the class. While pure exercises of memory are perhaps still satisfactory, a certain poverty of thought, weakness of judgment and incoherence in the train of ideas appears always more distinctly. Many patients try by redoubled efforts to compensate for the results of their mental falling off, which is at first attributed by parents and teachers to laziness and want of good will. They sit the whole day over their work, learn by heart with all their might, sit up late at night, without being able to make their work any better. Others become idle and indifferent, stare for hours at their books without reading, give themselves no trouble with their tasks, and are not incited either by kindness or severity.

Hand in hand with this decline of mental activity there is a change of temperament, which often forms the first conspicuous sign of the developing malady. The patients become depressed, timid, lachrymose, or impertinent, irritable, malicious; sometimes a certain obstinate stubbornness is developed. The circle of their interests becomes narrower; their relations to their companions become cold; they show neither attachment nor sympathy. Not infrequently a growing estrangement towards parents and brothers and sisters becomes noticeable. The patients remain indifferent to whatever happens in the family circle, shut themselves