Prognosis and Treatment Approaches

acquaintances, highly placed persons, viragoes, enemies; the physician is Charlemagne. Sometimes the patients have a certain feeling of the change which has taken place in them, but no clear understanding of its significance. A patient, who was usually extremely irritable and violent, had intervening periods in which he was accessible and exaggeratedly grateful, but without real insight into the disease; he thought then that he was

as if awakened from a long sleep

to be after some time again dominated by the old delusions.

Mood is as a rule somewhat exalted or indifferent, but sometimes also gloomy, strained, and inclined to violence. In conversations of any length the patients fall into a certain excitement. They usually bring forward their delusions with fluency and prolixity, often in a very confused and desultory manner, while they are able to give information about remote questions clearly and to the point. Their conduct is frequently somewhat affected; occasionally grimacing is observed. Their speech is usually interspersed with peculiar turns of expression, but specially neologisms. A patient spoke of the “alphathunderbook,” the compendium from the court law or university lexicon, called himself the “cyklesteraksander and brain inventor”; Aksander was a Christ-brain, Cyklester a penitential body, Rader someone who speaks out of one without one noticing it. A female patient declared that princes had as dynasty people (suite), “feds,” dukes, “fesochs,” emperors and kings, “fusaltos”; the world was a “cultar,” a magnet, which forces vegetation. Her parents drove into the “Erdall,” were merely killed; her ancestor was “Doreal” with the Emperor of Iceland, which again consisted of Rumenien, Ostrumenien, Jeromin and Morasto; her grandfather went with Emperors and Kings into the Erdterail, in order to hold Tyram or Tore. Another female patient thought that she had been dragged in as a poodle and suction-pump. Many sentences may be quite incomprehensible. “That is a great family word, that will never end, without war and deeds,” declared a female patient; she had as a child experienced the most wonderful things, the virgin icxx0 and no night;

that is beautiful and payable

Silly plays on words also, nonsensical rhymes and witticisms are not infrequent. A female patient said that she was Socrates, should do “so grad’es”; a patient connected “Chamisso — Scham is so,” “Wahrheit — wahrer Heid,” “Doktor — Dogg-Tor”; another spoke of Leipzig “the town of the sacred masses and of the sacred religions, of the sacred legions.” A third thought that fractures could be cured by introducing the new calendar and abolishing fractional arithmetic; he wanted by the abolition of prostitution to turn “Klagenfurt” into “Ehrenfurt.” In spite of such occasional nonsensical interpolations the patients can still usually make themselves quite intelligible, especially if the matter in hand has not to do with their delusions; they sometimes write faultless letters.

An example of the peculiar utterances of such patients is given in the following transcript:

You will probably know what that means to be an immortalized spirit, although I am only a simple beer-brewer and had to go through that if anyone raises himself from a low rank to the nobility. It was certainly from birth Count Eberstein, but first by the head-disease and the strained memory the accession has resulted, so that he is Frederick William III. from then onward the fourth, which therefore has direct relation with William I. and Frederick III. That means the immortalized and that means that he is not it now for the rabble; we know well why the pictures and flags have been waved to the right, that means the right one will come… I know that I am mad; that means that I must suffer by head-disease and by memory voices, but then it is also possible that a common fellow comes to high station; that will mean much, if one is to have memory for the general staff and the government… You have not the least idea how much goes on in my head; I often think it must burst. You don’t know at all what happens to me at night; I frequent in fact the most glorious marble halls at night; then I am many miles away. Last night I had 20,000 marks in my hands; here there are only twenty and ten mark pieces, but there there are also thirty mark pieces; that was not in dream, but by day; there was on the pieces the President of America from Hamburg. Indeed you don’t know at all what intercourse I have at night, the expanding pictures; then I am indeed in glorious, wholly unknown towns, where I never was before, or, as last night, in glorious ships on the sea. In this world-globe, which I frequent at night, it is quite different from here; it is perhaps a continent behind the moon. I am far away outside, though I am in the asylum. In December, January I have eaten cherries there, when here in winter-time there are certainly none at all… For eighteen and a half months already I have been William I.; but through the length of time I have obtained the double order of the crown; at that time I was already as much as the most mighty King on earth. If Jesus Christ had been let go free and not innocently crucified, perhaps it would have happened to him as to me, by the head-disease throughout become equal with his father… .

On the one hand the mental activity of the patient appears here in the vivacity of the descriptions, on the other hand there is occasional derailment into quite incomprehensible turns of expression and trains of thought. Further, the fabulous exalted ideas come to the front with wonderful nocturnal experiences probably pointing to pseudo-memories, lastly, there is the morbid feeling which shines through and which is brought into singular relations to the exalted ideas.

The Course

The morbid form described here is progressive. In time the utterances of the patients usually become gradually more confused and more disconnected. The neologisms and queer turns of expression often greatly prevail; the behaviour also often becomes peculiar. The emotions become duller with rapid explosive outbursts of violence and transient states of excitement. Many patients remain permanently capable of work; others are limited to long-winded speeches and the composition of comprehensive, scarcely comprehensible documents. The rapidity with which this dementia develops appears to be very varying. Sometimes it is already distinctly marked at the end of four or five years; I also know, however, cases in which after one and even after several decades, in spite of the most extraordinary delusions, there could be no talk at all of real confusion or at least not of a higher degree of psychic weakness.

Among my patients the male sex preponderated with 60 to 70 per cent.; almost the half of the patients were in age between thirty and forty years, a quarter in each of the decades below and above that. In one case there was at the age of twenty-one years a state of depression which gradually disappeared again, and which was followed between forty and fifty by the development of the delusional attack. Some of my patients were described as gifted, vivacious, but fantastic, others as frivolous, stubborn, self-willed; several of them had a criminal career behind them and fell ill in prison.

Delimitation

In this form also it must remain doubtful whether it corresponds to an independent morbid process. It cannot be denied that there exist many similarities with the paranoid forms of dementia praecox, especially with the cases which issue in drivelling dementia; also the falling ill in prison which was repeatedly observed, could be advanced for this view. Nevertheless, the clinical picture is so peculiar that a separate description of it might in the meantime be justified, even though it should turn out later that gradual transitions to the forms named exist. In any case it is noteworthy that here, in comparison with the so unusually severe disorders of intellect, the injury to volition by the morbid process is wholly in the background, if we do not regard a certain mannerism and the disorders of speech. In connection with this it must be emphasized that the mental activity of the patients as a rule remains strikingly well preserved. They may appear in their conversation extraordinarily confused, but at the same time be vivacious and accessible, and because of the absence of volitional disorders act quite reasonably. In this connection they recall to mind the cases of confusion of speech formerly described, from which, however, they are to be distinguished by the delusions which are here so extremely luxuriant. It might be conceivable that a nearer relation existed between these two forms or at least between parts of them, as at present we are not yet able to judge whether the peculiar delusions observed in this form may or may not be regarded as an essential morbid symptom. Naturally the possibility must also be remembered that the cases brought together here under this point of view are perhaps among themselves by no means of the same kind.

The Treatment

The treatment of the morbid forms discussed in this section has essentially to keep in view only the timely care of the patients who are almost always in need of institutional life, and further the preservation, as far as possible, of their psychic personality by suitable occupation.

INDEX

Adolescent insanity, 224

Age, 209, 224

Akataphasia, 70

Alcohol, 92, 235, 241, 259, 301

Ambitendency, 50

Ambivalence, 50, 248

Amentia, 275

Aphasia, 83

Apperceptive dementia, 76

Association, 19

Association experiments, 19, 263

Ataxia of the feelings, 35

Attention, 5

Autism, 49, 52, 248

Auto-echolalia, 43

Auto-echopraxis, 43

Auto-intoxication, 244

Automatic obedience, 37, 107, 142

Baths, 279

Blood, 85

Blood-pressure, 84

Bodily symptoms, 77, 207

Calculation tests, 24

Castration, 278

Catalepsy, 141

Catatonia, 42, 79, 80, 86, 116, 131, 145, 254, 257, 261, 266, 267

Causes, 224

External, 240

Cerebro-spinal fluid, 87

Classification, 89

Clinical forms, 89

Complexes, 35, 51, 91, 246

Conduct, 96, 115, 119, 126, 136, 173, 191, 202

Consciousness, 17

Constraint of movement, 40, 148

thought, 22

Degeneration, 235

Delimitation, 252

“Délire chronique,” 253, 284

Delusions, 26, 94, 112, 118, 124, 133, 154, 268, 284, 302, 310, 315

Dementia, Agitated, 116, 122

Apperceptive, 76

Circular, 117

Confusional speech, 177, 256, 328

Delusional depressive, 109

Drivelling, 197, 206

Dull, 199, 206

Manneristic, 201, 206

Negativistic, 203

Paranoid gravis, 154, 252

mitis, 165, 252, 256

Periodic, 129, 256

Silly, 94, 200

Simple depressive, 103, 208

Simplex, 90

Derailments in speech, 65, 70

train of thought, 72

Diagnosis, 257

Disintegration, 76

Dissimulation, 273

Drawing, 59

Dreams, 67, 69, 247, 250

Dysesthesiae, 167, 272, 317

Echolalia, 39, 56, 142

Echopraxis, 39, 142

Electricity, reaction to, 79

Emotion, 32, 74, 96, 270

Endogenous dementias, 1

Engrafted hebephrenia, 225, 260

Epilepsy, 274

Ergodialeipsis, 47

Ergographic experiments, 79

Evasion, 21

Flexibility, waxy, 38, 115

Flow of talk, 56

“Folie morale,” 259

Frequency, 224

Freud, 91, 246, 249

General conditions of life, 231

General psychic clinical picture, 74

Germ, injury to the, 234

Gibberish, 68

Hallucinations, 7, 103, 109, 117, 122, 135, 155, 166, 193, 271, 286, 304, 316

Hallucinatory verbigeration, 11

Hallucinatory weakmindedness, 192

Hebephrenia, 89, 94, 224

Hebephrenia, engrafted, 225, 260

Headaches, 77

Hearing of voices, 7

Hereditary predisposition, 209, 232, 258

Hysteria, 270, 309

Ideas, hypochondriacal, 103, 134

of exaltation, 29, 95, 114, 125, 135, 158, 171, 287, 302, 310

influence, 16, 28, 124, 135, 287, 317

persecution, 27, 105, 112, 124, 166, 284, 305, 310, 316

reference, 31

sin, 27, 105, 112, 124, 133

sexual, 16, 30, 157, 169, 288, 318

Idiocy, 260

Idiosyncrasy, personal, 235

Imbecility, 260

Immunization, 278

Imprisonment, 118, 124, 133, 154, 177, 241, 272, 327

Impulsive actions, 40

Incoherence of thought, 20, 56

Infections, 240

Influence on thought, 12, 170

volition, 37, 170

Inner negativism, 49, 51

Inquisitiveness, 7

“Intellectual negativism,” 21, 49

Internal speech, 67

Intrapsychic co-ordination, 75

Judgment, 25

Jung, 246, 249

Leucocytosis, 281

Life traumata, 35, 51

Mania, 308, 315

Manic-depressive insanity, 131, 256, 260, 309

Mannerisms, 45, 107, 163, 284

Memory, 17

Menses, 85, 129

Mental efficiency, 23

Mental over-exertion, 240

Metabolism, 86, 243

Mood, 106, 114, 119, 125, 136, 152, 161, 172, 178, 190, 195, 196, 198, 199, 201, 202, 205, 267, 293, 306, 314, 325

Morbid anatomy, 213

relation to the clinical picture, 219

Mortality, 211

Mutism, 65

Negativism, 21, 47, 108, 115, 141, 163, 265

in speech, 64

Neologisms, 67, 140, 179, 284, 325

Nomenclature, 3

Nourishment, 87, 102, 144

Obedience, automatic, 37, 107, 142

Objections, 3

Occupation, 281

Oedipus complex, 91

Orientation, 17, 111

Packs, wet, 279

Parabulia, 47

Paralogia, 21

Paralysis, 275

Paramimia, 75

Paranoia, 276, 284, 300

Paranoid forms, delimitation of, 252

Paranoid weakmindedness, 195

Paraphasia, 67

Paraphrenia, 2, 253, 277, 282

confabulans, 309

expansiva, 302

phantastica, 315

systematica, 284, 308

Parathyroidin, 278

Parathyroid glands, 278

Parergasia, 47

Perception, 5, 105, 111, 123, 291

Personal idiosyncrasy, 235

Personality, 53, 76

Poems,