Emotional and Volitional Disorders

Ideas of Sin

Very frequently there are also ideas of sin, especially in the beginning. The patient has misgivings about his past life, reproaches himself. He is a wicked fellow, has made mistakes, has told lies and committed theft, has deceived his wife, has killed his children, has said something about the Kaiser, has destroyed religion, has thought “God swine,” is to blame for the war, for the death of a nobleman, is bringing misfortune on his family; everyone has died on his account. He is the last Judas, is rejected, is damned for time and eternity, is the anti-Christ, cannot be saved, is to vow allegiance to Satan; his children are in hell. He is looked on as a great criminal, accused of theft, of indecent assault; he must die for the sins of the world.

Ideas of Persecution

Not less various are the ideas of persecution that are developed. Allusions are made to the patients; they are watched, stared at, spied on, laughed at. They are influenced by sympathy, bewitched, stunned, chloroformed, hunted like a wild animal in flight. Suspicious personages meet them in the street; there are people in the cellar; the slater will kill them; the policemen are coming to drag them to court. A raven appears at the window, which will devour their flesh; there are serpents in their bed; the black cat is coming; hellish spirits are threatening. The physicians give them poisonous pills, sprinkle poison in their ears; the air is also poisoned; the breakfast is made dirty with urine; there is human flesh in the food. The patient is murdered, executed, burned, cut to pieces, sawn asunder, dissected alive, trampled by a horse. His children are ill; his wife is in prison; his daughter has been killed; his brother is dead; his little boy has fallen out at the window; all Jews are being beheaded; a mother who thought her children were in danger, prepared to drown them. At night they are ill-treated; their flesh is tampered with, their breath is twisted off, their neck is broken by pressure, their strength is drawn out of them, their blood is driven off, the nape of their neck is broken, their skull is being proved; one can “tear him with words from below upwards”; with words his “legs can be shaken off.” His brain is injured; in his head everything is taken part in, thoughts are “made incarnate”; there is another spirit in his body. His nature is excited, his semen is driven off, an assault is made; the nurse makes sexual advances. As has been mentioned formerly, the persecutions are frequently connected with the nearest relatives. His family will bring the patient to the gallows; his father will kill him; his mother is a witch; a female patient asserted that she had been sexually ill-used by her father. The wife is contaminated by others and will poison the patient.

The idea of the change which has taken place in the patient, often takes very singular forms. The patient feels himself weak, gloomy, not right in his head, “not as it ought to be.” His head is “a rubber tube filled with blood”; everything is rebellious in him. His brain will burst, is heavy, has broken through; his understanding is destroyed by onanism; the patient cannot think alone, so cannot live outside. He had eaten the disease with a sausage, said a patient; another said that he was ill because of a disappointment in England and in Kaiserslautern. His face is a death mask, his heart is dried up, hardened, swollen; his bones rattle; loops of his intestine come out at his ear; his blood vessels are burst; the connection between intestine and stomach is broken off; everything is torn off and drawn together. The patient has no longer a stomach or an intestine or a motion; he has little children in his neck, serpents and snails in brain and body, a glazier’s diamond, a church tower in his breast, a frog in his stomach. He will not get better, he will not be alive tomorrow, is not a human being any more, is a guinea-pig, the northern lights, is dead, no longer in the world, is in another world; “I am as if dead-born,” said a female patient. A patient said that he must make the Talmud, his wife the Acropolis of Athens and then marry a grand gentleman, while he was being murdered. Perhaps such senseless utterances are connected with hallucinations; Bleuler suggests obscure associations caused by remote similarities of ideas or sounds, perhaps also indirect associations.

Exalted Ideas

In a number of cases exalted ideas are present also, mostly for the first time in the more advanced periods. The patient will be rich, will have good things to eat, get a situation on the railway of the Grand Duke, has an excellent memory, possesses means to make people omniscient, has the “imperial attack,” must go to the Kaiser. An inheritance of a million is being kept back from him; his mother is not his own mother, his father is a Count, Prince of Leiningen, the Grand Duke, the Emperor Frederick; he himself is a millionaire, Prince of Hesse, possesses a third part of the world; “Everything belongs to me, but there are also shareholders,” declared a patient. The patient is divinely gifted, is the vicar of Christ, the son of almighty God, feels the spirit of the Saviour, is inspired, fights for the faith, has the Bible and the world in his head, lives eternally; the spirit goes forth from him; a patient declared he was the bride of the Holy Ghost. Women are “the bride of a gentleman in a white suit,” hope “to get a husband, gentlemanly and aristocratic”; they are countesses, angels, “mother of the world,” the bride of Christ, their sons are princes; a female patient said she was the Mother of God, but had also earned it.

Mood is at first anxious and depressed. The patients mourn, they howl, they break out into convulsions of weeping, even though they often seem singularly indifferent in comparison with the delusions to which they give expression. Very frequently ideas of suicide come to the surface; the patients beg that something should be put into their coffee, that they should be killed because they cannot live any longer; that they should be beheaded as they will not get really well again. Many patients also make attempts at suicide, sometimes impulsively with great energy, sometimes more as in play. Several patients jumped out at the window; a patient threw himself before a train; a female patient stabbed her breast with a knife. A man lay down in front of a beer wagon in order to let himself be run over; another beat his head against the wall; a female patient “tried how drowning feels.” Not at all infrequently exalted moods are interpolated in the periods of anguish, giggling, grinning, and laughing, especially in the further course of the malady; also states of irritated excitement, outbursts of obscene abuse, and sudden dangerous assaults on the surroundings often occur. A few patients display in the beginning of the disease an exaggerated piety; they kneel, they pray, they read pious books continuously, they wish to go into a cloister; a female patient procured the robe of a penitent; another reproached the clergyman in church that he did not preach rightly. Sexual excitement is expressed by undressing, taking down their hair, improper talk, violent masturbation, which sometimes is ascribed to constraint; a female patient lay down in a missionary’s bed; a male patient urinated on his sister-in-law.

The Activities and Behaviour

The activities and behaviour of the patients have in part a certain connection with their hallucinations and delusions. They listen at the window, speak secretly against the wall, exert themselves to ward off invisible people; a patient begged to be allowed to sleep in the cellar, that he might not hear the voices; another was afraid of the alarm clock. Many preach, wish to confess their sins, ask the public prosecutor for protection. A female patient hid herself for several days and nights in the forest for fright. The aversion to relatives leads not infrequently to hostile assaults. A patient threatened his mother with a knife; another was going to kill his father with his scythe.

Very frequently, however, a motive for the conduct of the patients cannot be found at all; we have rather to do with impulsive actions, such as are so frequent in dementia praecox; for ought we know, vague delusions may often play a part. The patients throw things on the floor, tear the clothes off their body, seize hold of the physician by his face, steal things from their neighbours; bite their handkerchiefs; a patient who was given an injection immediately bit the part of the skin away. Another set the mill going by night, and then set fire to a hay stack, in doing which he was severely hurt. Many patients devour beeswax, dirt, drink the bath water. The assaults on the surroundings also may be wholly impulsive; a patient felt himself urged without any comprehensible motive to kill his sister, and stabbed her without more ado in the arm.

But further we meet in the patients here also all the peculiar volitional disorders which were discussed before. They often show waxy flexibility, often also echo-phenomena; they let themselves be pricked without offering any resistance; they assume singular attitudes “on command,” make faces, blink, utter inarticulate cries, shake their heads, make senseless gestures, pull out the hair on their genitals, lie about in corners, salivate into their handkerchiefs, behave in a silly way, “like a flapper.” They speak in a whisper, affectedly, mincingly, in a singing tone, using many foreign words, a foreign language; they address the physician by his first name, carry on confused, drivelling conversations, verbigerate, give utterance to silly plays on words and senseless doggerel, suddenly break out into bleating laughter. Negativism is also frequent. The patients become unapproachable, give either no answer or an evasive one, “because they do not need to say it,” do not shake hands, “because they have no time,” hold their hand before their mouth, do not eat because they think they must not, or “because they live on the word of God,” but they take food secretly or appropriate their neighbours’ food. They force their way out, they resist, they do not let themselves be undressed, or they keep no clothes on, they lie the wrong way in bed, disown their name, do not trouble any more about their surroundings, do not occupy themselves, remain lying in bed in a state of indifference. Occasionally there is developed a pronounced stuporous behaviour; ten years after the appearance of severe morbid phenomena a patient sank for the first time into stupor of long duration.

The Course of the Disease

The course of the disease, which generally is progressive, was in 14 per cent. of the cases collected here interrupted by improvement more or less complete, which lasted as a rule one to five years, but occasionally six or seven or even nine years, till another exacerbation ushered in a terminal state. This issue was in 20 per cent. of the cases a simple weak-mindedness, in which certainly the possibility of dementia progressing still further must be reckoned with. Nearly quite as frequent was the sinking into states of dementia, sometimes of dull, drivelling, negativistic stamp, seldomer manneristic. Seizures were observed in 27 per cent. of the cases. The form here discussed corresponds, therefore, with respect to the final issue to about the average, but inclines little to remissions and is accompanied with striking frequency by seizures. It includes not quite 13 per cent. of all the cases. Of the patients 55 per cent. were men, this corresponding just about to the average; 48 per cent. had not yet passed their twenty-fifth year. This form seems accordingly to prefer somewhat the more advanced periods of life, a circumstance to which we shall later have to return.

The Agitated Dementias

The next of the larger groups of the cases includes those in which states of excitement more severe and lasting longer are developed. According to the kind of clinical symptoms which appear, but specially according to the clinical course, we shall here be able to separate out some subordinate groups. Further, I think that on historical grounds I should keep apart and later discuss separately that form of dementia praecox in which peculiar states of excitement are associated with stupor, as it essentially corresponds to the picture of catatonia delineated by Kahlbaum.

Circular Dementia

The first subordinate group, which on account of the nature of its course we may perhaps name the circular form, at first shows a relationship with the clinical form just discussed, in as far as it also begins with a period of depression and generally is accompanied by vivid delusions. The development of the disease takes place gradually in about 56 per cent. of the cases, often after trifling symptoms have appeared a long time in advance; about 18 per cent. of the cases begin acutely. The patients become melancholy, anxious, resistive, morbidly contemplative, monosyllabic, stare steadfastly in front of them, and express thoughts of death. They complain of sleeplessness, nightmares, oppression in their head, sleepiness; they are indifferent, forgetful, have an aversion from work, are sometimes restless, irritable and violent, suffer from poverty of thought, weak-mindedness, have great ideas, but no energy, as the relatives of a patient stated. Not infrequently a distinct morbid feeling exists at the same time. The patients are afraid that they are becoming insane and ask for help. A patient desired admission to the hospital because he had become insane; such improper thoughts were always occurring to him. Another stated that he had suffered from his head for a year and his thoughts were weakened. A third said that he had been slightly weak-minded for three years through onanism.

Hallucinations are very commonly present, specially those of hearing. The patients see shadow-pictures, ghosts, dead people, their dead parents, one of their children without a head, two devils; light is reflected on to them and they are dazzled. They hear the children screaming, a band of robbers with chains rattling in the wall; the bed speaks, the devil chats in their ear; a man who has been hung speaks. Their name is called out; they are hoaxed, mocked, grossly abused, tormented with the telephone. Unhappy souls are calling; whole poems are sounded in front of them; there are “secret gossiping,” voices as from a distance, inward voices of thought, suggestions, inspirations, the thought-telephone. Thoughts are drawn off from the patient, manufactured, suggested; people try to tempt him to suicide; he must kill his child; God forbids him to work; he carries on dialogues in the distance. “It is the hopper of Nuremberg; one has it simply inside one’s head; the machine is always going on,” explained a patient. His feet are besprinkled, a stream is carried through his head; a patient had the feeling as if his eyes were being pressed out; a female patient complained of a vulvar smell.

Delusions are predominantly of a depressive character. The patient feels himself constrained, “inwardly repressed,” he is “utterly confused”; “my mind sometimes goes away,” said a patient; another said that he was dead; a female patient said that she had lain in chloroform. Their heads are hollow, their brains are rent, burnt, their blood and their stomachs are in bad condition, their bowels are detached, their voice is frozen, their throat is going to close. Something is being done to their ears; the patient feels himself influenced, especially in the night; there is a transference, “something false in things”; “electricity is the whole business.” Signs are given; people march with the patient keeping step with him, look at him suspiciously, wish to thrash him; agents, policemen, parsons persecute him. He is bewitched, laughed at, teased, sold, and sold for immoral purposes, dragged about the whole house by night, is an object of scorn and derision; he is stunned, beaten on his head with a hammer. Filthy and unchaste deeds are committed; a female patient thought that she was always having children.

The husband is dead; the children are “executed”; the physician administers poisonous powders; the patient is to be killed, burned, he will have a leg cut off; he knows “what happens underground.” He is to blame for everything, he is the devil himself, has stolen money, blasphemed God, dishonoured his children and mother, is possessed of the devil, is going into the convict prison; he is being tried by God, will suffer, will eat snails for three months and die of hunger; will be forced to chains; his feet are to be cut off; the devil is sitting in the wall. His wife wishes to poison him, takes sides with parsons; his father will strike him dead; his sister-in-law is a poisoner; father and brother take the part of the persecutors; he must therefore provide himself with weapons. Everything is changed; the brother is exchanged; the husband is quite different; a female patient asserted that two different men came by turns to her. The physician