THE 
Alienist and Neurologist. 
VOL. XX. 
ST. LOUIS, APRIL, 1899. 
No. 2. 
OUTLINE OF PSYCHIATRY IN CLINICAL 
LECTURES.* 
PS YCHO - PH YS10LOGICAL INTPODUC TION. 
DR. C. WERNICKE, 
Professor in Breslau. 
I. 
MENTAL DISEASES ARE BRAIN DISEASES, BUT YET DIFFER 
FROM THEM PRACTICALLY. PROJECTION SYSTEM 
AND CENTRAL PROJECTION FIELDS. ORGAN OF 
ASSOCIATION. BRAIN DISEASES TO BE DEFINED AS: 
DISEASES OF THE PROJECTION SYSTEM, MENTAL 
DISEASES AS DIFFUSED DISEASES OF THE ORGAN OF 
ASSOCIATION. CONTRAST OF PRIMARY AND SECON- 
DARY IDENTIFICATION IN THE MATTER OF SPEECH. 
THE subject for our consideration, the science of mental 
diseases, is, in reality, a part of internal medicine, but 
owing to its practical importance and for other reasons of a 
more extrinsic sort, it has at all times demanded and received 
♦Translated by Dr. W. Alfred McCorn. 2 
Outline of Psychiatry in Clinical Lectures. 
special treatment. Unfortunately it is this part, which has 
been backward in its development and is now in the posi- 
tion occupied by general medicine a century ago. You know 
that then a developed pathology in our modern sense, i.e., 
one based on the morbid derangements of function of indi- 
vidual organs, did not exist, and that therefore certain 
symptoms, which recurred with special frequency, if also 
in the most diverse groupings, were given the importance of 
disease types. At this stage the medical knowledge of dis- 
eases did not far exceed that now prevailing among the 
laity, when cough, palpitation, fever, jaundice, chlorosis 
and emaciation were considered true diseases. This is 
exactly the present state of psychiatry, at least among the 
majority of alienists, its representatives. Certain symptoms 
of special pregnancy form for them the real nature of the 
disease, so a depressed state of the emotions in the broad- 
est sense the condition of melancholia, the exalted mood 
with an excess of movements that of mania, and the like. 
Now a whole multitude of these supposed diseases are 
differentiated. But as naturally the combination of symptoms 
is by far more varied and complex, so the necessity arises 
of making the artificial boundaries, first broader, then 
narrower, which has been done by different observers in 
very different ways; in spite of all efforts to bring the cases 
of disease artificially into a form, so that they fit into the 
scheme, there still remains a large number which cannot 
be adjusted and no way be made to fit. Indeed, he who 
judges impartially and possesses the requisite experience, 
finds that the great majority of cases will not conform to the 
usual mode of consideration. Therein I am pleased to admit 
that psychiatry has recently made a material advancement. 
The work of men like Griesinger, H. Neumann, Kahlbaum, 
Meynert, Emminghaus and others has not been in vain. 
But even these prominent investigators have succumbed to 
the temptation of confounding individual symptoms with the 
nature of disease, and how debased the average position of 
psychiatry is to-day can be estimated by the fact that the 
prevailing theory of insanity, whose merit consists of an 
easy nomenclature, now enjoys general recognition and C. Wernicke. 
3 
could be regarded, by a thinker like Meynert, e. g., as an 
advancement. 
Under these circumstances the teacher of psychiatry is 
apt to tarry too long with the symptomatology, if the stand- 
ard of another discipline will be applied. But his task will 
be clearly defined, he will proceed as in the other disciplines 
of medicine and must deduct the symptomatology from the 
known attributes of the organ, of whose disease it is a ques- 
tion, i.e., in our case from the attributes of the brain. 
Only in this way is the prospect offered us of gaining a 
natural, i.e., based on its nature, and likewise exhaustive 
classification and comprehension of the symptoms. 
The hypothesis that mental diseases are brain diseases, 
is now disputed by no one.* If we accept this, we must 
soon add: diseases of the brain of a special kind and special 
location; for they are in no way identical with the so-called 
organic brain diseases, which are far better known to us. 
If we bear in mind the classification of brain diseases into 
focal and general, mental diseases certainly cannot be in- 
cluded among the first, but perhaps among the latter. There 
are two general diseases which are included among the 
organic brain diseases: meningitis and progressive paresis. 
Nothing would hinder us from adding to them the mental 
diseases as a third category. But now the question arises: 
what are the fundamental signs by which this third category 
is differentiated from the other two so-called organic? 
To get more into this question, we must occupy our- 
selves a moment with the symptomatology of brain diseases. 
All symptoms of brain disease are, as you know, either focal 
or general. The two general diseases of the brain desig- 
nated, which belong to the organic brain diseases, are 
examples of those with prominent general symptoms in the 
clinical picture. But on the other hand they are characterized 
by the fact that focal symptoms also occur in them, indeed, 
it may be said they are never entirely absent; whereas 
mental diseases do not present these focal symptoms, conse- 
quently mental diseases represent general diseases of the brain 
♦Only a difference of opinion prevails a§ to how far they are of a functional nature or 
due to palpable changes. 4 
Outline of Psychiatry in Clinical Lectures. 
of a special kind, as they are never accompanied by focal 
symptoms. 
The importance, which the focal symptoms attain accord- 
ing to this definition in our subject, makes it seem advis- 
able to keep their nature fully in mind. Through Meynert 
we have learned that the voluntary muscles and sense organs 
are connected with the cortex of the cerebrum by conduction 
paths, which extend in physiological continuity through the 
brain, spinal cord and peripheral nervous system. The sum 
of these paths, in which the law of isolated conduction pre- 
vails, he calls the projection system, and thus clearly and 
unmistakably expresses the fact of physiological continuity 
in contradistinction to anatomical continuity—a fact which 
by recent research is proven to be perfectly true. Corres- 
ponding to the division of the cerebrum into two hemispheres, 
the projection system is also divided into two halves, as is 
known, with the arrangement that motion and sensation of 
each half of the body is associated with the opposite cere- 
bral hemisphere.* The expression “projection” is evidently 
borrowed from optics; as here the course of the rays through 
a system of lenses is to be followed exactly, so, in spite of 
all interpolation of ganglion elements in the paths of the 
projection system, the physiological continuity and isolated 
conduction are universally preserved. The majority of the 
focal symptoms may be readily traced to local interruption 
or stimulation of the conduction paths in the projection system. 
A second series of focal symptoms may be traced to 
the fact that the terminal, respectively stations of origin, of 
the paths contained in the projection system are located in 
different parts of the cerebral cortex. The law of isolated 
conduction prevailing in them is thus extended to their anas- 
tomoses in definite cortical areas of the cerebrum. Such 
terminal stations of the projection system,—we will call them 
projection fields—are for example known for the optical tract 
in the occipital lobes, for the acustic in the temporal lobes, 
for motion and sensation of the leg, arm, facio-lingual 
region in the so-called upper, middle and lower thirds of 
the two central convolutions, for the motor speech tract in 
*On the whole that applies at least. C. Wernicke. 
5 
Broca’s convolution. Of course this does not imply that the 
mode of projection within this region causes nearly the same 
arrangement as is found in the fibres of a peripheral nerve. 
On the contrary we know that in the projection fields of the 
cortex, nerves lying far apart in the periphery unite in a 
common junction and cite, as the best known example, the 
projection field of speech in Broca’s convolution. As we will 
see later, the matter of function must therefore be decisive 
as to the manner of their projection in the brain cortex, 
because only the functionating nervous system is connected 
with the cortex. Here is involved a second attribute of the 
projection fields: the projection fields of the cortex are like- 
wise the places where the memorial images of the various 
functions of the nervous system are located. The localiza- 
tion of memorial images then follows the same principle, so 
that the occipital lobes are the places of the optic, the 
temporal lobes those of the acustic memorial images, the 
so-called middle third of the central convolution—the arm 
region—likewise contains the memorial images of the tactile 
impressions gotten by the hand. The fading of these defin- 
ite categories of memorial images belongs to the focal symp- 
toms of brain disease. 
Therefore the focal symptoms prove to be characteristic 
throughout by the fact that they show the disordered function 
of the projection system, be it in its paths, be it in the 
projection fields of the cortex. Then the focal symptoms of 
the brain are all to be traced to functional disorders of the 
projection system, and its terminals in the different projec- 
tion fields of the cerebral cortex, so mental diseases are 
distinguished from the two other so-called general organic 
diseases of the brain by the fact that the projection system 
and the projection fields are not thus affected sympathet- 
ically. 
We are not as yet fully informed as to the extension of 
the projection fields in the cortex and their exact location. 
But it could be readily conceived that the advancement of 
our knowledge in this matter will show, that the entire 
cortex of the cerebrum is occupied by these projection fields. 
In our search for a locality, which is the site of the disease, 6 
Outline of Psychiatry in Clinical Lectures. 
have we not then made an end to the brain and resorted to 
transcendentalism? Well, this is not the case, there is 
rather at our command, besides the projection fields, an 
anatomical basis of large extent, which we may claim, with 
good right, to be the site of mental diseases, namely the 
system of association fibres serving for the union of the 
projection fields. If this is so, mental disorders then are the 
special diseases of this organ of association. 
We are forced to assume the destruction of these asso- 
ciation paths in certain focal diseases of the brain; they 
form, in fact, the natural transition to mental diseases. A 
case of the sort occurs in certain rare examples of so-called 
transcortical aphasia. 
For ages the hope has existed that in aphasia the 
starting-point would be found, which would pave the way 
to the comprehension of mental diseases. That this hope 
has not deceived us, that there are true cases of aphasia, 
which are the most intimately connected with known mental 
diseases, the patient, whose condition will now engage our 
attention, may prove to you. 
This patient* now presents very plainly the traces of 
a severe mental disorder, which he had from 1885 to 1889. 
He stands and walks in a definitely fixed posture, but which 
has not hindered him from working at his trade as a 
cabinet-maker and comfortably supporting himself and his 
family. All the questions we ask him remain unanswered, 
or answered only by gestures. In fact he is entirely speech- 
less and for five years has not been able to utter a sound. 
Still he understands nearly all that I say to him, as you 
can plainly see by his gestures and the execution of requests 
made of him. Still if I ask him certain other questions or 
make certain other remarks, he plainly shows that he does 
not understand them. Consequently he does not possess 
perfect comprehension of language, but only to a certain 
extent—always the same,—while he has entirely lost the 
motor function of speech. 
This state of complete motor and partial sensory aphasia 
has developed from a definite mental disease, which for the 
*Verhandlungen des Congresses fur inner.e Medicin. Wiesbaden 1890, p. 272. C. Wernicke. 
7 
present 1 will call a motor psychosis and has then continued 
as a permanent defect. In the course of this disease mutism 
and verbigeration occurred temporarily, two psychotic symp- 
toms, which also affect the domain of speech.* 
If we try to get a better comprehension of this con- 
nection, we must keep in mind the different forms of 
aphasia, which are established by clinical observation. For 
this purpose follow me for a moment to the neighboring 
province of the so-called organic brain diseases. 
Two projection fields of speech are known, a motor 
and a sensory. The motor (m) is the place of origin of 
the motor speech path (mp), a part of the projection system, 
which leads to the nerve nuclei of the mddulla oblongata 
participating in speech. It is also the seat of memorial 
images of movements occurring in the act of speaking or 
motor speech ideas. The sensory speech field (5) contains 
the central termination of the sensory speech path (sp) and 
also of the acustic nerves, but it is likewise the site of the 
memorial images of speech clang or, as they are called by 
Helmholz, the clang images of the words. The clinical 
picture of motor or sensory aphasia occurs accordingly as 
the motor or sensory projection field is destroyed. 
But we will now waive consideration of our patient for 
a moment, who is in fact an anomaly, for the insane are 
not aphasic as a rule. The sensory speech path and the 
sensory speech field are usually intact in the insane, they 
can understand all that is said to them. They are also in 
full possession of their motor speech function, in so far as 
it depends on the integrity of the motor speech path and 
the motor projection field. Nevertheless we find the striking 
phenomenon, that the answers of the insane are often 
irrational and irrelevant, or seem to have no relation to the 
question asked. How is this phenomenon to be explained, 
must we still hold to the presumption that the correct 
answer is the expression of normal brain function? Here 
there is only the one explanation, that the function of those 
nerve paths, which pass between the two projection fields, 
*The temporary speechlessness of the insane we call mutism; verbigeration the 
monotonous, usually rhythmical repetition of one or some few words. 8 
Outline of Psychiatry in Clinical Lectures. 
must be disordered. Hence insanity appears to us to be a 
disease of the association organ. But remember that in the 
current scheme of aphasia, those association paths are made 
use of, in that the sensory speech path sp and likewise the 
motor mp are regarded as continued through the cortical 
regions (projection fields), s and m to a supposed concept 
centre C. The transcortical paths sC and Cm are simply 
association paths, and in their province the functional dis- 
order must be located, which is manifested in the improper 
answers of the insane. But every mental disease, in so far 
as it is manifested in the patient’s perverse assertions, is 
for us an example of transcortical aphasia. The curious case 
of aphasia, in consequence of a mental disease, from which 
1 started, suggests the assumption that under certain con- 
ditions all the parts Cm and a great part of the paths sC 
may be interrupted in the course of the disease. Then a 
real aphasia, of the same sort as in our patient, will prob- 
ably occur. 
The assertion of a concept centre C in the scheme of 
aphasia has often been misunderstood. But that it was not 
to be avoided and therefore requisite is shown by the fol- 
lowing consideration. Sensory aphasia from destruction of 
the projection field s—cortical sensory aphasia, as I have 
called it, is characterized by the patients losing the mem- 
orial images of the speech clang and consequently the words 
are not recognized when heard again. But for the compre- 
hension of language evidently more is demanded than for 
the recognition of the word clang: the proper sense must 
be united with it. If we maintain the antithesis of word 
and concept, we can only mean that some of these paths 
pass through the cortical centre s to other cortical regions, 
which represent the related concept. In reality this sup- 
posed concept centre is distributed to places in the cortex 
widely separated. But it shows the necessity of differen- 
tiating two entirely different processes with respect to the 
comprehension of language. The one, the recognition of 
the word clang images, depends on the retained function of the 
projection field s, which we will call primary identification. 
The other process, the rise of the concept joined to the C. Wernicke. 
9 
word, depends on the function of association paths with this 
supposed concept centre. We call it secondary identification. 
If we compare the whole process with that of sending a 
despatch, as others have done, then s is the station where 
the telegram is received, but the real recipient is represented 
by C. The relation of C to the motor projection field of 
speech in m is very similar: here C is the real sender, 
but m the telegraph station from which the despatch is sent. 
In other words: the sense, the concept of the word rises, 
and it needs to be conducted by anatomical paths to the 
motor projection field of speech m, for the word to be spoken. 
If we call the mutual relations of C to m secondary 
identification, as we have a right to do in reasoning from 
analogy, so as the result of our consideration, the proposi- 
tion follows: The peculiar utterances of the insane are 
signs of disordered secondary identification. 
Progressive paresis must be assigned a very exceptional 
position among mental diseases; it can, as has happened, 
as well be included among the organic brain diseases. But 
still without doubt it is a mental disease. In the very 
frequent cases where it presents marked focal symptoms, 
foci are actually demonstrable, in which the otherwise dif- 
fuse disease process affects the projection system and the 
projection fields. But exceptionally there are cases of pro- 
gressive paresis, where such focal symptoms are only inti- 
mated, for these then show the paramount transcortical 
character of the disease. 
The comparison of aphasia with the speech symptoms 
of the insane has taught us that a disorder of secondary 
identification may be the common basis of mental disease 
and certain cases of aphasia. The harmony of the two dis- 
eases is explained by their like location in transcortical or 
association paths. We will discover their difference in that 
the mental disease affects, with individual choice, these 
paths separately, whereas the focal disease destroys compact 
masses. Exceptionally the general result of individually 
diseased paths is the same as that of a focal disease, and 
then a transcortical aphasia may follow a mental disease. 
Thus from the special location we postulate a special Outline of Psychiatry in Clinical Lectures. 
10 
kind of disease: this is characterized by the fact that it 
differentiates, in a certain measure similarly to degenerative 
neuritis, the individuals among the association elements, 
and, as we presume for the present, according to the analogy 
to degenerative neuritis, according to the form of the differ- 
ent function. 
II. 
CONCEPT CENTRE TO BE REPLACED BY SOME LOCAL- 
IZED IDEAS. INITIAL IDEA AND TERMINAL IDEA IN 
THE SPEECH SCHEME. GENERALIZATION OF THE 
SPEECH SCHEME. KINDS OF MOVEMENTS: EXPRESS- 
IVE, RELATIVE, INITIATIVE. DISORDERS OF SECON- 
DARY IDENTIFICATION ARE PSYCHOSENSORY, PSY- 
CHOMOTOR OR INTRAPSYCHICAL. 
Our previous speculation has demonstrated to you the 
contrast which exists between brain diseases and mental 
diseases, as soon as we observe the province of speech. In 
fact the pathology of speech forms one of the most familiar 
chapters in the province of brain diseases. The utterances 
of the insane again comprise such a large part of the 
symptomatology of insanity, that from this alone the right 
can be deduced to consider the insane at present from this 
single point of view. I hope that your understanding will 
be facilitated for the following exhaustive discussion by the 
fact that we hold to the simplified conditions of our example. 
We have to occupy ourselves still further with the 
(voluntary) fiction of a concept centre C. The advance- 
ment, which our clinical knowledge has gained from aphasia, 
shows most plainly that this present assertion was indis- 
pensable for the extension of our knowledge. To trace it to 
its true value I have only hinted at heretofore. Permit me 
to carry this suggestion somewhat further. 
As I have said above in speaking of the central projec- 
tion fields, we can consider it an assured fact that memorial 
images and ideas* are localized, i.e., joined according to the 
content to different anatomical regions of the cerebral cortex. 
This localization could be disregarded in the scheme of 
*See below for the different use of these two terms. C. Wernicke. 
11 
aphasia, and with some propriety the standpoint could be 
taken, that the receiver and sender of any dispatch in the 
imaginary concept centre C would be identical with all, the 
rest of the brain cortex and, as we must again say, the 
association system belonging thereto, so that the two pro- 
jection fields s and m are brought into an artificial opposition 
to all the other projection fields. On this oppositional posi- 
tion depends then the differentiation of the terms cortical, 
which relates to the two projection fields s and m, and 
subcortical or transcortical, according as it is a matter of 
paths, which lay on this or that side of these definite pro- 
jection fields. By this view the anatomical idea was im- 
plicitly given that the sum of the transcortical paths sC and 
mC could form a compound column, accessible to destruction 
by focal diseases, in the immediate vicinity of the two pro- 
jection fields s and m, while they must be regarded as 
radiating to the most diverse regions of the cortex. The 
clinical picture of transcortical motor and sensory aphasia 
seems to have been due to the rare accident that disease 
foci exactly invade the postulated site. That these rare 
cases are included among the focal diseases of the brain, 
will be entirely comprehensible. On the other hand the 
observation of a patient, whom I have presented to you, 
proves that such disease types can occur in the course of a 
typical mental disease, and so form a natural transition to 
mental diseases. 
It is essential to our purpose to really refrain from such 
rare occurrences. But if we stick to the chosen example 
and hold only to the principle of localized ideas, so we 
appropriately divide the centre C into two localized ideas 
joined by an association path, which we will term A and 
Z. A, the initial idea is united by an association path sA 
with the sensory speech field. Z, the terminal idea, is 
united by a similar path Zm with the motor projection field 
of speech. AZ is the association path. The scheme thus 
changed corresponds somewhat to the process occurring when 
an arithmetical problem is given the patient. Its compre- 
hension occurs in the initial idea A, its solution corresponds 
to the terminal idea Z, and when this is spoken, the Outline of Psychiatry in Clinical Lectures. 
12 
innervation from m occurs. Between problem and solution 
complicated trains of thought may occur, thus showing that 
the association path AZ may be conceived as divided many 
times. No special proof is needed that normally the whole 
process conforms to law, in a certain measure by previously 
formed paths, so that the result can be foretold. We can 
for the present assume that it is just the same with any 
question: the comprehension of the question is represented 
by A, the sense of the answer by Z, and the path inserted 
between embodies the fact that the answer arises from a 
more or less simple reflection. If we do not suppose the 
intention of being led astray, so must we recognize in this 
case in normal persons, the answers will occur in a very 
definite sense, which accordingly may be known before with 
approximate accuracy. The conformity to law, which may 
be here observed, depends, as we shall see later, on the 
principle of the beaten paths. 
The previously maintained example admits of an ex- 
tension, by which it may become the foundation of the 
whole symptomology of mental diseases. We have only to 
replace the projection fields of speech by any other projec- 
tion field. In the place of speech utterances any motor 
manifestation then occurs, and m represents this projection 
field, accordingly as the movement occurs in the arm, leg, 
back regions, etc. The central projection field of a sensa- 
tion replaces the sensory speech field. In fact it occurs the 
same in seeing as in the comprehension of the spoken 
speech clang. Here also the primary identification takes 
place in the central projection field of the optic nerve, but 
for the comprehension of whatever is seen the conduction to 
other projection fields, secondary identification, is essential. 
Without this secondary process the sight impression is lost 
to the one receiving it and remains unintelligible, like the im- 
pressions of hearing in transcortical aphasia. And this is 
true, as slight reflection shows, of all sense impressions. 
That this generalization of our scheme is permitted, 
even demanded, a closer inspection of our original example 
teaches. The answer, which 1 expect from the patient, 
does not need to be spoken; it may be written or com- C. Wernicke. 
13 
municated by silent pantomime and gestures, or in the per- 
formance of any chosen command. According to the muscles 
engaged in its execution, the projection field m will have a 
different significance and correspond to different places in 
the cortex. On the other hand my question, respectively 
my command, can be given without a spoken word, either 
by writing, pantomime, expressive movements of the hand 
or the like. 
A short time ago 1 said that our scheme with the 
proposed modifications can aid in the deduction of the 
symptomatology of insanity, in so far as it consists of 
the patients’ movements. But then this limitation is only 
necessary when we exclude from the movements the speech 
utterances, pantomime, attitude and all those manifestations 
of the patient within the province of expression, as corres- 
ponds to ordinary parlance and the views of the laity. But 
in the last instance there are also movements which are 
utilized for judging of the inner processes of an insane 
person, and for scientific consideration it would be an error 
to neglect this condition. And the more you really see 
of the insane and become acquainted with their symptoms, 
the more you will be convinced that finally nothing else is 
to be found and observed but movements, and that the 
general pathology of the insane consists simply of the 
details of their motor condition; for as a matter of course 
the loss of movement may be just as characteristic as its 
occurrence. 
We conclude from movements as to the processes oc- 
curing in the consciousness (in the organ of consciousness) 
of another. If these movements are those of speech, so 
this fact is much more tangible and evident than all the 
other movements. The symptomatology of the insane has 
then for its subject the movements, in so far as they seem 
to be the function of the organ of consciousness, in other 
words of the organ of association. We here find only the 
single reservation, which impairs the universality of the 
proposition. There are of course motions, which are inde- 
pendent of consciousness, like those of vegetative life, of the 
heart, respiration, the vascular walls, viscera; as well as 14 
Outline of Psychiatry in Clinical Lectures. 
the majority of reflex movements. As we will see later, 
these movements may be affected sympathetically in the 
insane, but then do not form the real object of observation. 
We will further find that in rare cases the state of the tem- 
perature and in almost all cases that of the nutrition, as ex- 
pressed by the body weight, is of great symptomatic signi- 
ficance. But the exceptions are thus exhausted, and we will 
see that they are all to be considered secondary and in their 
turn possess a conformable dependence on the motor mani- 
festations of the patients. 
We are then justified in disregarding the exceptions 
enumerated, and have merely to keep more closely in mind 
the movements as functions of the organ of consciousness. 
A classification according to practical points of view is 
essential. Therefore we distinguish expressive, reactive and 
initiative movements. As we will see, this classification has 
the advantage that it embraces the sum of all possible 
manifestations of motion, and therefore it is to be preferred 
to Meynert’s classification into movements of defense and 
offense, however portentious and fruitful this has proven in 
other respects,* it is defective and needy of improvement, 
in that a sharp boundary line between the three kinds of 
movement is often impossible. It is in the nature of the 
affair that certain movements of the one province come 
under another, that, according to the observer’s standpoint, 
it may be a matter of dispute into which province a certain 
movement is to be placed. However, for the present we hold 
to the classification, because it has stood the test in the 
clinic of mental diseases. 
By expressive movements we understand especially all 
those by which the affects and emotional state of a person 
are manifested. The speech movements largely serve this 
purpose, but not exclusively, and as far as they serve, they 
are speech movements in the broadest sense, so that they 
include, e.g., the plaintive tones and the groans of pain. 
Words, which especially serve this purpose, are, as you 
know, the majority of interjections. Laughing and crying 
are specific expressive movements, like general pantomime. 
♦See his Sammlung popular-wissenschaftlicher Abhandlungen. C. Wernicke. 
15 
But the expression of the face while at rest, depends on 
certain muscular actions, and also the attitude of the whole 
body, which may betray, as well as words or pantomime, 
the person’s affective state and affective condition. The 
movements of the entire body, serving for the expression of 
joy, mirth, arrogance, egotism, scorn, anger, anguish, sor- 
row, trouble, despair, hope, hatred and love are sufficiently 
known and appropriate that it will be unnecessary to de- 
scribe them here. Normally the person awake is always 
animated by an expression, therefore we have become ac- 
quainted with lack of expression as an important clinical 
phenomenon. 
The reactive movements are those following actual 
external stimulation. A person’s answers to questions, 
regardless of their content, are always to be regarded from 
this point of view of reactive movements. Also an answer, 
which does not consist of words, but of other expressive 
movements, when the person questioned, with a significant 
mien, places his finger to his lips, comes under the concep- 
tion of reactive movements. The absence of an answer 
may often be regarded as a significant symptom. The re- 
active movements, which are of great significance in the 
clinic of mental diseases, are especially the patient’s con- 
duct during the physical examination, toward the little favors 
shown by the nurses, toward requests of any kind, on the 
approach and greeting of the physician, toward the entirely 
changed situation in the rooms of the asylum. Also those 
movements, which are necessary for the gratification of the 
bodily wants, although they are to be traced to internal 
stimuli, must be included among reactive movements. It 
might, however, be proper to add the last category of move- 
ments to the initiative, while again many of the former at 
the same time fall into the province of expressive movements. 
At any rate it is to be again stated, that the absence of 
reactive movements is just as characteristic and valuable as 
a symptom in the insane as their morbid modification. 
By initiative movements we understand all those which 
arise spontaneously and are not due to an actual external 
stimulus. This negative definition includes a part of the 16 
Outline of Psychiatry in Clinical Lectures. 
expressive movements, while another part belongs to the 
reactive. We will then always have to judge of the ex- 
pressive movements, whether they belong to the initiative 
or the reactive. It might be asked, whether there are really 
initiative movements, i.e., those, which occur without any 
external cause; for usually an external cause may be dem- 
onstrated for an apparently spontaneous action. But such 
causes often have only the significance of exciting causes 
and recede in their importance before the preponderating 
internal motive, so the assertion of initiative movements is 
justified. In general the initiative movements consist usually 
of a whole series of individual motor processes and then are 
to be called actions. The whole conduct, behavior, actions 
of a person in a certain situation, all his movements, so far 
as they are not expressive and reactive movements, belong 
to the initiative. 
The nerve excitation, which takes place over the path 
sAZniy may be compared to a reflex process and this path 
called a “psychical reflex arc.” The movement innervated 
from m then appears as the result, as the tangible conse- 
quence of this process of excitation. The clinical method 
of psychiatry consists in studying the final result, in draw- 
ing a conclusion from the process as to how it occurred. 
As you will likewise notice, it is really the reactive 
movement alone, which may be compared in this way to 
the reflex process. If the reactive movement may now 
consist, as in the example we started with, of a spoken 
word or any other movement, it may always be very readily 
considered a consequence of an external stimulation, an 
external impulsion depending on processes of motion. How 
is it then with the other kinds of motion, the expressive 
and initiative? Evidently these also permit of the same 
consideration; for with the exception, that in initiative move- 
ments it seems questionable, whether they occur entirely 
without external cause, we will be justified in replacing the 
external stimulation by the memorial images of past stimu- 
lation and in every case, where the present external stimulus 
is wanting, to consider those memorial images as initial 
members of the movement occurring in the psychical reflex C. Wernicke. 
17 
arc. We may even go so far as to use the existing move- 
ment as a proof of this assumption. For as it is not con- 
ceivable without a cause, while an apparent cause is wanting 
for the movement, the actually existing movement can only 
be due to a force treasured up somewhere. But these sup- 
plies of reserve force are memorial images, as we shall see 
later. 
After these preliminary remarks we are now able to 
familiarize ourselves with the morbid derangements of move- 
ment, which are observed in the insane. They all depend 
on disorders of secondary identification, as I have above 
shown. But still 1 must remind you, that we have consid- 
ered as secondary identification, not only the relation of s to 
A, i.e., of the nearest sensory projection field to the initial 
idea, but also the process of excitation proven in the inverse 
direction of conduction from the terminal idea Z to the motor 
projection field m. We were justified in this, because the 
path Zm is an association path, as well as the other sA, 
and in these association paths the physical process occur- 
ring in them must always be identical, in whichever direc- 
tion it occurs. For the same reasons we can also infer the 
relation of A to Z to secondary identification. 
As it is always a matter of nerve paths, so a morbid 
change of excitability, respectively capacity for conduction, 
is always to be based on the disorder of secondary identifi- 
cation, and all possibilities are exhausted, if we keep in 
mind the three cases of lowered excitability, respectively 
capacity for conduction, increased excitability and perverse 
excitability. We will call the path sA psychosensory, the 
path Zm psychomotor, the path ZA intrapsychical. The 
possible cases are then contained in the following summary: 
Psychosensoty 
Ancesthesia 
Hyperaesthesia 
Paraesthesia 
Psychomotor 
Akinesis 
Hyperkinesis 
Parakinesis 
lntrapsychical 
Afunction 
Hyperfunction 
Pdrafunction 
The objection may be raised against this, that there are 
always disorders of motion, which oppose us in the insane, 
as 1 have stated, and that therefore the whole. symptoma- 18 
Outline of Psychiatry in Clinical Lectures. 
tology is exhausted in the three cases of hyperkinesis, 
akinesis and parakinesis. This objection is justified in a 
certain sense, and needs an exhaustive discussion. It is 
the easiest to refer it to the example of conversation, with 
which we started. If the patient is silent when he should 
speak, we will be able to consider this symptom a circum- 
scribed form of akinesis limited to the province of speech. 
If he presents the symptom of loquacity, it is likewise a 
circumscribed form of hyperkinesis. Whereas, if his answer 
is nonsensical in its purport, so one will be justified in 
ascribing this to parakinesis, but still a closer inspection 
would always be necessary, because then a certain mis- 
conception is to be expected and presumed. For practical 
reasons we will always be obliged to differentiate two 
entirely different things in the act of speech, namely the 
motor act as such and the purport of the works spoken. 
But as there are now really morbid modifications of the act, 
or as we may term it, of the formal part of speech, so it 
would be the more correct to employ the word parakinesis 
in this restricted sense. We have an example in the 
symptom of imperative speaking and the monotonous repe- 
tition of the so-called verbigerator. The same consideration, 
that the content must be differentiated from the formal part 
of movement, applies to all the expressive, as well as 
to the reactive and initiative. As it is possible for a 
patient to utter the veriest nonsense in formal words per- 
fectly correct, so the expressed affective condition in language 
perfectly correct can of itself be of a morbid nature, as well 
as his acts formally correct, but false in content. In all 
these cases then we will not assume a disorder of the 
psychomotor identification, but be constrained to seek the 
derangement in more remote parts of the psychical reflex 
arc. This corresponds to common parlance and the usual 
view, in that the means the patient uses to communicate 
his feelings, express affects, etc., are generally overlooked 
completely as self-evident affairs. After this discussion you 
will comprehend that in the insane, we often find symptoms 
of disordered identification, when the motor mechanism 
itself is perfectly intact. C. Wernicke. 
19 
NATURE OF MEMORIAL IMAGES. AFTER-IMAGES OF THE 
RETINA AND OPTICAL MEMORIAL IMAGES. THE AS- 
SUMPTION OF SPECIAL PERCEPTION AND MEMORY 
CELLS DO NOT SUFFICE FOR EXPLANATION. LOCAL 
SIGNS OF THE RETINA. IDEAS OF SIGHT. 
III. 
Ere I can introduce you further into the symptomatology 
of mental diseases, 1 must again return to the concept centre, 
so often mentioned, or rather, as you can apprehend more 
correctly, to the localized memorial images. You have be- 
come convinced, 1 hope, in the course of the discussion, 
that the presumed concept centre, as well as the concepts 
themselves, is incapable of localization in a certain sense. 
In the introduction to my first lecture I have asserted 
as a fact, confirmed by the experiences of pathology, that 
the central projection fields are localized in different terri- 
tories of the cerebral cortex. We must likewise ascribe to 
them the attribute of being places of memorial images, 
whence then a definite localization of the memorial images 
was to follow. We will have to make ourselves better 
acquainted with the nature of these memorial images. 
I might very briefly cite the clinical facts, which, in my 
opinion, completely prove the principle of localized memorial 
images: they are the clinical experiences of sensory and 
motor aphasia and the cases of so-called tactile paralysis 
of the hand. The first are now so well known that I need 
not go into them, but the latter must be especially consid- 
ered as to their significance. Here are two series of facts, 
which by their relation to each other, furnish the evidence. 
Cases of circumscribed cortical injury in the region of the 
so-called middle third of the two central convolutions, which 
leaves as a permanent defect the inability of the hand to 
recognize objects by touch, while real so-called sensory 
disorders are demonstrable only to a slight degree. Con- 
versely, cases of spinal or peripheral disease are observed, 
which are accompanied by the gravest disorders of sensa- 
tion, and, as I have especially shown, also of the so-called 
muscle sense or sense of position, and yet present only 20 
Outline of Psychiatry in Clinical Lectures. 
insignificant disorders of the tactile function. The last cited 
cases in a certain measure prove that even a very defective 
and faulty projection system conducts reports to the brain, 
which suffice for primary identification, if only the central 
projection fields and hence memorial images, tactile images, 
as we may call them in the preceding case, are retained. 
But the cases of the first kind can only depend on loss of 
the primary identification, if disorders of the projection 
paths are so slightly demonstrable. The principle of memor- 
ial images localized according to the projection fields is 
placed beyond doubt by such facts, and hence its application 
to all projection fields is warranted. 
If we return to our example of the organ of speech, we 
find the process of recognition—primary identification—joined 
to the hypothesis, that a fixed possession of memorial 
images is present. So the question arises: How is such a 
possession brought? Evidently it is a matter of a very 
special attribute of the nervous system, that it undergoes 
permanent changes by temporary stimulation, an attribute 
which we call memory. The memory of the nervous system 
is manifested, e.g., in that the faradic excitability of a nerve 
can be increased by frequent faradisation* The same stim- 
ulus later acts more readily, when it has often occurred 
previously, so that then a permanent change has taken 
place in the nerve, in consequence of temporary stimulation. 
All dexterity depends on this principle, all accomplishments. 
Paths, which were only passable with difficulty, become 
readily passable by repeated use, they become hollowed 
out, so to speak. Now, if such a memory is perceptible in 
the nerve fibres, it is very especially attained in the nerve 
cells or ganglion bodies. A reflex in fhe spinal cord, which 
is effected by these ganglion cells, occurs the more readily, 
as the more often it has previously taken place, and that it 
is here a matter of a special attribute of the ganglion cells, 
has been proven by the researches of Ward,t Jarisch and 
Schifft and others. The after-images of the retina have 
*Mann, Deutsches Archiv fur kiinische Medicin. 1893. 
tUeber die Auslosung von Reflexbewegungen durch eine Summe schwacher Reize, Du 
Bois-Reymond’s Archiv. 1880. 
lUntersuchungen iiber das Kniephanomen. Wiener med. Jahrbucher, 1882. C. Wernicke. 
21 
with good right been referred to the ganglion cells. In the 
brain cortex it is in the ganglion cells, to which must be 
especially ascribed the attribute of being permanently 
changed by momentary stimulation, that residues of it re- 
main, which we call memorial images. 
After what has been said it seems self-evident that the 
possession of memorial images or content of consciousness, 
as we will cali it, is directly dependent on the condition of 
the projection system and the sense organ, by means of 
which it has been acquired. The consciousness of a weak- 
sighted person, or one with generally poor senses, is there- 
fore different from that of an individual with normal senses. 
The person born blind will not be in possession of optical 
memorial images and therefore, in case he can be operated 
upon, will represent a state, which is also known to us 
from its pathological occurrence as the so-called mental 
blindness. Like the person born blind, the one born deaf 
has a content of consciousness, which is defective in a whole 
category of memorial images derived through the sense of 
hearing. In partial brain defects, as they have occasionally 
been observed in imbeciles from birth, who likewise have 
a sense defect, e.g., are deaf, the same absence of memo- 
rial images is seen as a consequence of the defective form- 
ation of the central projection fields. No less instructive 
in this respect is the comparison of the animal brain. As 
is well-known, man has only stunted olfactory lobes, while 
many families of mammals possess those constituting a 
considerable portion of their cerebrum, have a special ven- 
tricle and are covered with several superficial convolutions. 
How the consciousness of such an animal, e. g., the dog, 
differs from ours, daily observation teaches. It is filled with 
olfactory memorial images, in which the animal, sniffing 
about, manifests all the signs of a pleasant affective con- 
dition, like the epicure at the table, or the artistic eye at the 
sight of beautiful forms. The content of consciousness in 
this way shows its dependence on the condition of the pro- 
jection system and the central projection fields, a condition, 
which permits the statement: Consciousness is a function 
of the central projection fields. If the assumption is confirmed, 22 
Outline of Psychiatry in Clinical Lectures. 
then the further proposition is allowable: Consciousness is 
a function of the cortex of the brain mantle. 
If we now seek to further understand what we have to 
conceive by a memorial image, we will do well to keep in 
mind a definite example, like the optical memorial image. 
For this the comparison with the after-images of the retina 
is especially apt, which belong to the same sense province. 
How far is the comparison pertinent and warranted? As we 
have above seen, it is the ganglion cells especially, in which 
we trace the after-images of the retina to excitement out- 
lasting the stimulus; by a definite arrangement of these 
stimulated cell elements an image arises, which we are able 
to project into a definite space. This image is of a very 
limited duration in point of time. There is nothing to pre- 
vent the assumption of such cell elements in the central 
projection field of the optic nerve, we call them perception 
cells, in which the projection fibres first terminate. Would 
the assumption that the memorial image consists of the 
re-echoed excitement of the perceiving elements sufficiently 
explain the evident difference existing from the after-images 
of the retina? Much speaks against it. According to my 
experience at least, the attribute of spatial projection is 
completely absent in optical memorial images. They seem 
to me projectable into space only so far as they take a 
definite position to the person. Besides they appear to be 
of • unlimited duration. The last distinction is especially 
important. It may be hard to conceive, that the same 
perceiving element, which has once been used, should retain 
its permanent state of excitement, nevertheless it can soon 
after be engaged in a new perception from an entirely dif- 
ferent stimulus. It would really be expected that it behaves 
similarly as with after-image's, and that at least the subse- 
quent process of excitement always obliterates the preceding. 
We assume, e. g., it is a matter of the optical memorial 
image of a letter or a number. It can be accepted that for 
the origin of these memorial images, such retinal images, will 
essentially prevail, as occur at the place of the keenest 
vision, or very near it. Here only are the greatest number 
of sensory elements united, but the optical apparatus is C. Wernicke. 
23 
also very accurately adjusted for the images of this region, 
so that the sharpest images can occur here. Accordingly 
Nature has so arranged it, that for visual impressions, which 
excite our attention, the place of keenest vision is adjusted 
wholly involuntarily by proper eye movements, an impulse, 
which in the adult renders it very difficult to completely 
control his eye movements. Consequently many of the 
same retinal elements, which previously represented the 
image of the letter, will soon be demanded for the produc- 
tion of a new image, e.g.f the number, therefore the cells 
of the central projection field serving for perception. The 
assumption is wholly permissible and even probable, that 
the place of keenest vision in the retina may occupy rela- 
tively a very considerable space in the central projection 
field. The difficulty of explaining, under these circumstances, 
the memorial image by a special memory of the cells, is 
therefore unchanged. It has been attempted to overcome it 
by differentiating perceiving and remembering ganglion ele- 
ments and ascribe to the latter this special attribute of 
memory. Only the elements serving perception should 
represent a cortical projection corresponding to the points of 
the retina. However it seems to us the difficulty is not 
overcome by this assumption alone. The distinction between 
perception image and memorial image does not depend so 
much on a difference in the active elements, rather in that 
the common arrangement of the retinal elements concerned, 
or the form of retinal excitement is different in the different 
images, while the same retinal elements may have pre- 
dominantly cooperated in their origin. But the memory of 
the like mutual arrangement of the functionating elements 
or, in other words, the form of excitement, completes the 
psychological concept of the memorial image. 1 fully concur 
with Sachs* and Goldscheider.f that the assumption of an 
acquired functional union of simultaneously excited perceiv- 
ing elements by means of existing association paths is able to 
explain this special memory of the form of the retinal image, of 
*Vortrage liber Bau und Thatigkeit des Grosshirns. Breslau 1893. 
tUeber centrale >prach—Schreib-und Lesestorungen. Berlin. Klinische Wochen- 
schrift No. 4. 1892. 24 
Outline of Psychiatry in Clinical Lectures. 
the common arrangement of the stimulated points in the retina. 
When the same order of stimulation occurs and the retinal image 
is again recognized, the process may be conceived, as Ziehen* 
has done, that from the perceiving elements the memorial 
image is excited, because only the cell combination con- 
cerned is in a certain measure sensitive to this form of 
excitement (somewhat as sound-resonants respond only to 
definite combinations of tones). But this shrewd conception 
also depends on a comparison and does not relieve us of 
the necessity of explaining the fact of this “sensitiveness,” 
and so. we need the combination of perceiving elements by 
fibres or the process of association. We will see later, that 
an association of different sense impressions always occurs, 
when they have taken place simultaneously; just as we can 
here assume that the simultaneously excited perception cells 
serving perception are associated with each other and, be- 
cause on renewal of the same sense impression, the like 
form of arrangement is always renewed, also remain asso- 
ciated. The memorial image then would be simply an 
acquired association of perceiving elements of the central 
projection field. 
You see that in this conception the assumption of special 
memory cells is indispensable. In fact there are entirely 
different reasons, which have a bearing on this. 1 will only 
say here, that it would not be very comprehensible why 
the sensory activity leaves the memorial images, if the 
perceiving elements alone could be implicated and definite 
retinal points always corresponded to them. Also that the 
memorial images are not projected into space, like the after- 
images, then remains incomprehensible. Finally the struct- 
ure of the central projection fields in the cortex cannot be 
considered a contrary reason. A simple layer of ganglion 
cells, which are all connected by projection fibres, would 
satisfy the previous assumption. But in the cortex we 
everywhere meet with such a number of superimposed 
ganglion cells, and more so still in the optical projection 
field of the occipital cortex, that they by far exceed the 
number of projection fibres. All these considerations we will 
*Leitfaden der physiologischen Psychologie. Jena. 1891. C. Wernicke. 
25 
have to make use of in the future. In the meantime we 
claim that we are finally able to trace to an anatomical 
distinction the demonstrable differentiation between memorial 
images and the after-images of the retina, namely, the 
durability of the first, the instability of the latter: the cortex 
has association fibres, the retina has not. 
If the stability of the memorial images can be explained 
by the repetition of the same order of stimulation and this 
proposition can be applied to the special case of optical 
memorial images, we soon meet with certain difficulties. 
The retinal images, which are produced from concrete 
things of the world, are first large, then small, accordingly 
as these are near or far, but we must consider their mem- 
orial images as units. The mutual arrangement of the 
retinal points remains the same, and the images will be 
regarded as perfectly congruent, so that still corresponds to 
the psychological requirement, which we must place on the 
memorial image. But there are always different retinal points, 
whose arrangement in one and the same memorial image 
must be represented, and even in the simplest assumption, 
that the object is fixed, numberless images of different sizes, 
if also congruent, would always appertain to a memorial 
image. This difficulty is gotten over, if the intelligent 
hypothesis of H. Sachs is accepted. According to it the so- 
called local signs of the retina are determined by two fac- 
tors, namely, the meridian in which they lie, and their 
distance from the central point. For each half meridian of 
the retina a special muscle arrangement is required, by whose 
cooperation the eye ball is turned so that the source of 
light falls on the macula. This muscle combination is the 
same for all points of the same half meridian, only the 
amount of innervation varies and increases with the removal 
of the retinal point from the fovae centralis. Whereas 
for the different half meridians the muscular arrangement 
is always different. The varying size of images of fixed 
objects then depends alone on the sensation of innervation 
of varying intensity, while the anatomical factor, the com- 
bination of different muscle effects, remains the same. In 
other words, this retention may be expressed as follows, 26 
Outline of Psychiatry in Clinical Lectures. 
and transferred to the relations of the cortex. The percep- 
tion cells of the central projection field associated with the 
retinal points of any half meridian have collectively the 
same associative connection with a definite point of the 
central projection field of the eye movements. We must 
consider the latter divided into as many different muscle 
combinations (“ideas of eye movements”), as there are half 
meridians in the retina. That is, of course, to be understood 
cum grano salis, as it is a matter of continuously graded 
series of muscle representation, not of special points. If 
this view will be taken into account, the optical memorial 
image is characterized, besides the attribute we have become 
acquainted with, in that the perception cells constituting it 
are associated with definitely localized ideas of motion of 
the central projection field of the eye movements. By 
repetition of the same visual perception, besides the asso- 
ciation of the perception cells with each other, one between 
the corresponding, also localized ideas of movement, occurs. 
We will call the thus broadened concept of the optical memo- 
rial image visual idea. We now see that in spite of changed 
size of the image, the last named components of the visual 
idea remain the same, when they refer to the same object. 
That the same considerations apply to the retinal images, 
whose position is asymmetrical to the central point of the 
retina, you can see from Sachs' book, whose perusal l can- 
not too urgently recommend to you for the introduction to 
our subject. 
A second difficulty, which is not to be misconstrued, 
consists in the different initial position of the object, of 
which distinct images are produced. An equilateral triangle, 
a cross are again recognized, whether the triangle now 
stands on its base or apex, the cross is upright, oblique or 
lies down. How can the same memorial image occur? To 
this is to be replied: by far the largest number of objects 
of the world and in consequence of this their retinal images, 
do not present this difficulty, for they have a fixed position 
with respect to our eyes. In comparison to these are the 
objects movable and changing their position, respectively 
retinal images on the one hand in the minority, on the C. Wernicke. 
27 
other they usually have a definite, habitual position with 
respect to our person. If we still take into account the 
ability of our eyes to so place themselves that a known 
image appears again, so the difficulty arising from the chang- 
ing position of objects will be but slight. But it cannot be 
denied, that under certain circumstances the memorial images 
are not numerous enough to identify objects occurring in 
strange positions. We do not recognize inverted letters; 
several well-known optical illusions depend on the same 
defect, and how strange seems to us the image of a person 
walking about when seen through a convex lens, and is 
thus inverted! 
Admitted, that by this consideration several difficulties 
are removed, still the great number of cell groups required 
to harbor the optical memorial images alone will seem 
enormous. Yet experience teaches that the healthy brain is 
still able to acquire new memorial images, then an abund- 
ance of elements serving this purpose must always be 
present. 1 will soon call attention to a miscalculation, which 
perhaps may make this difficulty appear exaggerated: as 1 
will show later, we are inclined to overestimate the number 
and variability of concrete things of the world; in like de- 
gree we consequently underestimate the frequency of the 
recurrence of the same impressions. 
IV. 
THE CONCRETE CONCEPT AN ASSOCIATION OF MEMO- 
RIAL IMAGES. CONSCIOUSNESS OF THE WORLD. 
NUMBER OF CONCEPTS. NECESSITY OF CASUALITY. 
As we have found that the optical memorial images are 
acquired associations of perceiving elements of the central 
projection field, and that the form of stimulation determines 
the kind of this association, we are'justified in transferring 
all sense provinces to the central projection fields. The 
acquirement of memorial images depends very generally on 
the attribute of the central projection fields, that their per- 
ceiving elements, i.e., those ganglion cells which are directly 
united with the projection fibres, are united with each other 
by association fibres, the special fibres of each projection 28 
Outline of Psychiatry in Clinical Lectures. 
field. In the future we will speak of olfactory, acustic, tac- 
tile and gustatory memorial images, without going further 
into their nature. But 1 must especially call your attention 
to the fact that each sense province offers special problems,* 
and that these simplest psychical elements, the memorial 
images, may be of a complicated sort. By virtue of this 
possession of memorial images recognition, primary identifi- 
cation, occurs. If we limit ourselves for the sake of sim- 
plicity to the concrete things, which alone form the material 
for sense perceptions, we thus gain a content of conscious- 
ness, which is the sum of the memorial images of concrete 
things. It is now readily conceivable that within this sum 
definitely fixed groupings are to be differentiated, which 
always correspond to the attributes of a definitely 
concrete thing. One and the same concrete thing generally 
gives rise to several sense perceptions always recurring in 
the same way. The coincidence of these different sense 
impressions causes their memorial images to be associated. 
In this way to every concrete thing an acquired association 
of memorial images of different senses corresponds, and this 
association is the more stable, as the more often the same 
concrete object comes within the scope of our senses. In 
this way we gain an anatomical basis for those psycholog- 
ical qualities, which are now called concepts. We are now 
able to differentiate the stability and extent of the concept, 
but in concrete things we can differentiate essential and 
non-essential attributes, accordingly as they are always in- 
herent to the thing or changeable. The extent of the con- 
cept of course extends to the non-essential attributes, as 
they must always show a certain constancy dependent on 
the nature of the thing. Of each concept, as is readily 
conceived, a curve might be constructed, in which the ex- 
tension (“extent of the. concept”) would be shown by the 
axis of the absciss, the intensity (“stability of the con- 
cept”) by the height of the ordinate. 
We must therein perceive the nature of secondary 
identification, as contrasted with the primary, that from each 
individual component of the concept- the sum of all the 
*See Ziehen. C'. Wernicke. 
29 
others, i. e. the whole concept may be excited. The anatom- 
ical basis for the acquisition of these functionally homo- 
geneous groups of cell elements is the presence of the 
association fibres between the different projection fields. 
We will call these transcortical association paths, as con- 
trasted with the transcortical fibres of each projection field. 
The content of consciousness, which we have now become 
acquainted with, embraces then the concepts of concrete 
things, or, as we call them, the concrete concepts. The sum 
of these concepts we may distinguish as consciousness of the 
world, for in these concepts, in fact, we possess a true pic- 
ture of the world. 
As you will soon notice, in the consciousness of the 
world is contained the apparatus for simple processes of 
deduction, it is the same as also serves for secondary 
identification. From words 1 have heard, from the bark of 
a dog, from a definite odor, I deduce the presence of a per- 
son, a dog, a certain flower. Almost all deductive processes, 
which refer to the nature of concrete things, are of similar 
nature and then, as we have seen, only individual cases of 
secondary identification. 
The content of our consciousness consists hence not 
only of memorial images, but second of very definite com- 
plexes of memorial images firmly united with each other by 
association, the concrete concepts. The number of concepts 
corresponds to the number of concrete objects. Perhaps it 
astonished you, when 1 said that only some few and always 
the same objects would come within the scope of our senses. 
Do not, you may ask, the things of the world in almost 
infinite number and indescribable variety come within the 
scope of our senses? Fortunately there is a very definite 
answer possible. The number of words gives us an idea of 
the number of concepts: of the number of these concepts, 
which a certain individual possesses, by the number of 
words he uses. One of the most comprehensive minds that 
ever lived or will live, is without doubt Shakespeare, his 
vocabulary was consequently unusually large: it amounted 
to fifteen thousand (1). How much we must deduct from 
that, when we will limit ourselves to the concrete things of 30 
Outline of Psychiatry in X2 link at Lectures. 
the world! Not everyone is a Shakespeare, but it will 
astonish you if we go to the other extreme (within the civ- 
ilized nations!): the vocabulary of an English sailor is not 
over a few hundred. The number of concrete things is then 
not so large, their variety not so significant, as we are 
really inclined to estimate, especially when the number of 
ganglion cells in the brain cortex is stated, according to 
Meynert’s calculation, a thousand millions. Still the same 
concrete object must proportionately come within the scope 
of our senses extremely often, for in this way a firm union 
of definite memorial images must arise of what we have 
called concepts, will now seem intelligible to us. 
It now appears self-evident to you, that the conscious- 
ness of the world is definitely dependent on the world or is 
a function of it, as we may express it. Quantitatively, as 
the above examples show, this is beyond any doubt. Yet 
as contrasts we must not only keep in mind the extremes, 
like Shakespeare and the sailor, but principally the con- 
sciousness of the city resident, well educated and living in 
the complicated relations of civilization, and of the country- 
man, fisherman or hunter, growing up in solitude and edu- 
cation neglected. But also the qualitative difference of the 
consciousness of the world must also be astonishly great. 
Think of the contrast between a tropical resident, living in 
the midst of a luxurant fora and fauna, in a world of color, 
and the inhabitant of the polar region, who in a short 
Summer sees only the traces of vegetation. 
It well pays to still tarry a moment with the note- 
worthy fact of association and keep its conditions in mind. 
The majority of associations, which could heretofore interest 
us, depend on the coincidence of the impressions. This of 
course does not imply an explanation, but the fact is unde- 
niable, that the memorial images of coincident sense impres- 
sions are associated, whether its occurence is due to an 
inner connection or the merest accident. Only accidental 
occurrences are not so readily repeated, therefore their 
association does not become so firm as those conforming to 
law. 
(1) According to Meynert. Sammlung von popular-wissenschaftl. Vortragen,1895, p. 5. C. Wernicke. 
31 
The association of the different memorial images.with 
each other is a second example of the appearance of the 
so-called beaten paths, i. e., the union between them there- 
fore becomes so firm, because these paths have been so 
often used. 
Besides association by coincidence, we know a second 
kind of association, that by sequence. I need only to refer 
to the fact, that in every attempt to learn a thing by heart, 
it plays the chief role. There are whole series of associa- 
tions, which, early impressed upon us, remain in our pos- 
session for life; I refer to the alphabet, multiplication table, 
the Lord’s Prayer, etc. This association by sequence alone 
gives us knowledge of things conforming to law. Whenever 
a definite sequence of phenomena recurs, we believe in a 
conformity to law, and very especially will we be strength- 
ened in this belief, if we are able to voluntarily produce the 
first phenomenon, to then see the second phenomenon fol- 
low. That is the reason why experiment so irresistibly con- 
vinces us. But it is readily conceivable, that if an inner 
connection of the two phenomena is not thus disclosed, it 
will readily be proven by the presence of that association 
path, which has been used before in the same process. 
The necessity of causality, to speak briefly, is a congenital 
fault or merit of our brain. The phenomena of the world 
are far from possessing a connection with each other; the 
bond, that unites them, exists only in our brain and does 
not serve to unite the things themselves, but only the traces 
they leave in our brain. 
We will see later, that a coincidence of sharp sense 
perceptions is impossible, owing to that attribute, which has 
been called narrowness or unity of consciousness. In reality 
only one sense perception occurs at a time, the second, 
apparently simultaneous, either follows or precedes it. 
Association by coincidence seems to be merely a case of 
ordinary association by sequence (1). 
After having said so much of association, we cannot 
help seeing the difficulties which interfere with the compre- 
hension of this process. On a former occasion (2) 1 com- 
pared it to the conduction of a wave through a system of 32 
Outline of Psychiatry in Clinical Lectures. 
closed tubes. Meynert and Ziehen recently have made 
similar comparisons. At any rate the fact of association may 
be explained by the assumption of conducting paths between 
the anatomical localities where the memorial images of the 
several senses are localized. In the white matter of the 
brain mantle, as well as in the cortex itself, a multitude of 
fibres are demonstrable, which serve for the union of differ- 
ent cortical areas, so its anatomical basis is undoubtedly 
provided. When two cortical areas of one and the same 
central projection field are excited in the act of primary 
identification, or different projection fields simultaneously by 
means of the projection system conveying stimuli of the 
world in the act of secondary identification, the path of 
union extending between them is likewise put in vibration, 
the resistances, which oppose the conduction of the process 
of excitement become weaker and weaker, the oftener the 
process is repeated, and more the path is beaten, as 1 for- 
merly termed it, facilitated, as it has been called of late. 
It is not implied by this, that this path must be continuous, 
we can only claim a physiological continuity for it, as 
for the paths of the projection system. On the contrary the 
fact very definitely indicates, that there is a special layer 
of ganglion cells of the cortex, that of the spindle cells, 
which by their form and position seem related to the asso- 
ciation system, also that ganglion cells are interpolated in 
the association paths. In general it is contradictory to our 
view to assume nerve fibres, whose origin from a nerve cell 
cannot be proven. The simplest assumption then will be, 
that each spindle or association cell sends out two nerve 
fibre processes in opposite directions, which by their terminal 
branches are attached to the ganglion cells of the projection 
fields to be associated. There is no difficulty in fancying 
that the ganglion cells of a central projection field implicated 
in primary identification are all united by these association 
fibres provided with an association cell, although under these 
circumstances an immense number of association fibres are 
required, if computed from the number of perceiving ele- 
(1) As to the further conditions of association see Ziehen. 
(2) In my first work on aphasia. C. Wernicke. 
33 
ments to be combined. But as soon as the first physio- 
logical union, the memorial image, is disregarded, or only 
the next complicated case of visual ideas (see page 29), or 
the association between visual ideas and the memorial 
images of another projection field are kept in mind, the 
difficulty of fancying a definite material basis for the process 
increases immensely. Recently Goldscheider has correctly 
emphasized this circumstance. We will, however, consider 
the present possibilities. It seems wholly impossible to 
employ this scheme, which is conceivable within a projection 
field, namely that each perceiving element is anatomically 
united with every other by previously formed paths, for the 
union of memorial images with each other; as large as the 
number of fibres here at command may seem, it would be 
wholly insufficient in comparison to the almost infinite large 
number which must result from these combinations. Hence 
follows the absolute necessity of making another assump- 
tion, which simplifies the conditions of association. For the 
reasons above stated, but especially the last, 1 consider the 
idea justified, that the psychological unity of the memorial 
image corresponds to an anatomical unity. There could be 
e. g. cells of definite layers of the cortex, which received 
fibre processes from the above mentioned association cells, 
but also united with the perceiving or projection cells. 
There is nothing impossible in considering the processes of 
excitement of a definite cortical layer distributed to many 
elements, in a certain measure embracing the ganglion cells 
of the next cortical layer. Besides reflect, that for our con- 
sciousness it is the memorial images, not the perceptions, 
which remain associated, if the acquirement of association 
depends on the coincidence of the perceptions. Further 
reflect, how slowly and difficultly firm associations between 
different senses are acquired, but with what security they 
are retained, when once acquired. The opening of this 
road may be attended with very special difficulties. 
(To be Continued.) THE 
Alienist and Neurologist. 
VOL. XX. 
ST. LOUIS, JULY, 1899. 
No. 3. 
ORIGINAL CONTRIBUTIONS 
OUTLINE OF PSYCHIATRY IN CLINICAL 
LECTURES.* 
PS YCHO - PH YS/OLOGICAL INTRO DUG TION. 
DR. C. WERNICKE 
Professor in Breslau. 
THE BODY A PART OF THE WORLD. CONSCIOUSNESS 
OF THE BODY A FUNCTION OF THE CENTRAL 
PROJECTION FIELDS. ORGANIC SENSATION AND 
SENSORY CONTENT OF SENSATIONS. AFFECTIVE 
TONE OF THE SENSATIONS. THE LARGE VISCERA 
ARE REPRESENTED IN THE CONSCIOUSNESS OF THE 
BODY. 
V. 
OF what significance the views now gained have for our 
subject, 1 can again best show you by a simple 
example. Assume that some one awakens from profound 
sleep or pathological unconsciousness. You can now per- 
ceive the sign, that his organ of consciousness again func- 
tionates in his recognition of the world and the deductive 
processes occurring normally. The consciousness of the 
’Translated by Dr. W. Alfred McCorn, Resident Physician "River Crest," Astoria, L. 
I., New York City. 35 
Outline of Psychiatry in Clinical Lectures. 
world was lost to the person asleep, or rather, it had not 
functionated so long as the unconsciousness lasted.* But 
after it has returned how does the person previously uncon- 
scious behave? We notice that he corrects an uncomfort- 
able position he has assumed, that he feels of his body to 
be convinced of its condition, and that his interest is essen- 
tially directed to his own body. The consciousness of the 
body has returned, and now we must keep this process more 
closely in mind. 
If the proof was given above, that only by means of 
the projection system sense impressions and hence reports 
from the world reach our brain, so the simplest consider- 
ation teaches that it is true of parts of our bodies. Only 
by the nerve paths, which unite a definite part of the body, 
for instance the arm with the brain, is the brain connected 
with it; if they are interrupted, as is often observed in 
mechanical injuries, so anything can happen to the part of 
the body, it can be pressed upon, pricked, pinched, bruised 
or burned without the least perception of it being conveyed 
to the brain and reaching the consciousness. Such occur- 
rences are most often observed in the arm, owing to the 
brachial plexus being relatively superficial and so the 
most subject to the action of external violence. 
As this example may be applied to all other regions of 
the body, hence it is true in general that the integrity of 
the nervous system is essential for perceptions of our body 
to occur. The unconscious person, whose brachial plexus is 
destroyed, can no longer identify the arm as his own on 
awaking. Consciousness of the body hence seems in gen- 
eral to be a function of the sum of the nerves of feeling, 
or in other words of the projection system. Meynert’s 
remark, referring to the significance of a transverse section 
through the projection system at the level of the cerebral 
peduncles, also applies to the consciousness of the body; 
only the bodily perceptions from the retina and olfactory 
organ could occur if this operation could be performed. 
*The contrast of functionating and latent consciousness will repeatedly oppose us, they 
correspond apparently to different states of one and the same anatomical basis. Therefore' 
we have not the least reason to go further into it at present. C. Wernicke. 
36 
Fancy that in place of this section, which cannot be actually 
performed, another operation could be made, which is as 
little possible, but just as conceivable as the other. The 
calvarium is opened, the brain gently lifted from the base 
of the skull and, without sustaining incidental injuries, 
raised above the calvarium; blood vessels, nerves, medulla 
and spinal cord must have sustained no injury by this 
stretching process. Then the brain appears to us in its 
true form, as the real sentient and moving being, only 
equipped with a machine, which furnishes the apparatus for 
the reception of sensory stimuli, for the execution of move- 
ments, but in relation to the brain constitutes a part of the 
world, only that this is inseparably united to the brain. 
Sense impressions, then as before, would become conscious, 
only slightly retarded, movements would be possible just as 
formerly, only the transmission of the command would take 
more time. The brain then could be compared to a zoo- 
phyte, as Meynert has exemplified, Which is provided with 
antennae, sense nerves, and with tentacles, the nerves of 
movement. That these antennae are equipped with a com- 
plicated sense apparatus, these tentaculae with a special 
motor apparatus, the muscles attached to a skeleton, does 
not prejudice the value of the comparison. 
The consideration we had advanced with respect to the 
sense impressions, will apply entirely to our body. The 
consciousness of the body is first acquired, and like' the 
consciousness of the world, in that reports from the most 
diverse parts of the body reach the brain in its central pro- 
jection fields and their residues leave memorial images. 
A part of these projection fields are known to us 
grossly, and localized in definite places of the cerebral cor- 
tex. There can be no doubt that each of the cortical areas 
experimentally determined by Munk, which he has named 
arm region, leg region, head region, ear region, trunk and 
neck regions, have the importance of central projection 
fields for these parts of the body. That these experiments 
are transferable to the human brain, human pathology fur- 
nishes incontestable proof, if the more exact boundary of 
the regions in man is still to be expected, In my opinion, 37 
Outline of Psychiatry in Clinical Lectures. 
there can no longer be any doubt that each region repre- 
sents the total sensibility and motility of the part of the 
body named, the arm region the central projection field for 
sensation and motion or, in other words, all the nerves of 
the arm. 
Then a relation arises, which deserves our undivided 
attention. All these regions of the body are clothed with 
the tactile organ of the skin, its central projection fields 
hence contain the representation of sense surfaces. On the 
other hand the representation of the body in the “con- 
sciousness of the body” will not seem complete if the cen- 
tral projection fields of the special senses are disregarded, 
for the olfactory mucous membrane, the retina, the organ of 
hearing, the mucous membrane of the tongue and pharynx 
serving taste, although for special sense functions, always 
constitute the most important parts of our body. Therefore, 
we will have to place the consciousness of the body for these 
organs, if a special projection field is not demonstrable (as 
e. g. for the mucous membrane of smell and taste by cer- 
tain branches of the fifth), in central projection fields 
already familiar to us, so that our cortex is quite well sup- 
plied with a consciousness of the world and consciousness 
of the body. We here meet with relations of a more com- 
plicated kind, which necessitate our return to the most ele- 
mentary process of simple modal sensation. 
What we had previously learned of sensation, and what 
furnishes the material for the construction of a conscious- 
ness of the world, we may term sensory content of the 
sensations. But it must be evident to you that every sen- 
sation posseses another quality, which we have until now 
intentionally neglected, and which is generally differentiated 
as the affective tone of the sensation from its sensory 
content. This affective tone of the sensation is especially 
closely related, as 1 hope to convince you, with the con- 
sciousness of the body, in that it is differently colored 
according to the place the stimulus acts and so in a meas- 
ure furnishes a local sign for the consciousness as to which 
part of the body has been affected by the sense stimulus. 
The sensations, which are combined with an intense affec- C. Wernicke. 
38 
tive tone, show a close relation to the mechanisms of move- 
ment, which properly co-operate and apparently serve for 
the protection of the body. We do not usually take heed 
of these organic sensations, they escape us, as our attention 
is occupied with the sensory content of the sensation. Still 
somewhat stronger stimuli act on our consciousness, so that 
we neglect the sensory content and turn our attention to 
the organic sensation of the part of the body concerned. 
But usually appropriate movements of defense occur pre- 
viously. A few examples will show this. Fancy that you 
are unexpectedly touched on the arm, perhaps in a crowd, 
you immediately think of a person or object from which the 
contact has come, according to its kind. If you are struck 
violently, so that it causes pain, you draw back the arm 
and try to protect yourself from further injury. Your 
attention is then turned to the part injured. It is much the 
same with loud noises. Everyone jumps back when a shot 
is fired unexpectedly close to the ear, and no one is able to 
stand in close proximity to a passing express train, even if 
he knows there is no danger. Here it is essentially the 
din which produces the intense organic sensation and causes 
the involuntary recoil. A simpler form of movement of 
defense, closure of the eye, we observe from the action of 
bright light, particularly when it occurs suddenly in the 
dark, and under these conditions it is painful. On organic 
sensation also depends the first adjustment of the eye 
to the point of illumination by a mechanism of movement, 
which I have already mentioned in speaking of the visual 
ideas. All these examples of movement cited, first of a 
simple, then of a more complex sort, we will have to con- 
sider in Meynert’s sense as movements of defense and 
offense, and remember that their original source is to be 
sought in suitable congenital reflexes. I will mention Pflii- 
ger’s celebrated experiment in which the decapitated frog is 
not only capable of movements of defense, but even of 
appropriately modifying them, as in wiping off the acid 
applied to the skin, it uses the opposite leg as soon as the 
one on the side irritated is cut off. These modifications 
may be the acquirement of the individual, they always 39 
Outline of Psychiatry in Clinical Lectures. 
occur through the gray matter, to which we essentially 
ascribe a reflex action, and there can be no doubt that cer- 
tain congenital reflexes are appropriate in the person and 
serve for defense, to say nothing of the lower animals with 
predominant spinal organization. The lowest organized ver- 
tebrate shows within this organization more than simple 
reflex movements, in that it, like the decapitated frog, pos- 
sesses the ability of certain appropriate adjustments. But 
where a powerful cerebrum exists, as in mammals and espe- 
cially in man, we see similar mechanisms of movement 
transferred to the central projection fields of the cortex (as 
it has been shown experimentally e. g. by Munk in the 
movements of the eye). The appropriate modification of 
the movement is to be observed in both cases according to 
the place on the body affected. It shows us that the chief 
purpose of the organic sensations is to protect the body. 
The local signs of the retina referred to above in 
speaking of the visual ideas, may now appear to you in a 
new light. They apparently spring from the organic sen- 
sations of the retina; for we saw that the sentient retinal 
elements act on the motor mechanism of the cortex accord- 
ing to their position, that the fovae centralis is always 
turned to the stimulus, and therein a movement of defense 
or offense in Meynert’s sense must be perceived. In fact, 
it must prove equally useful in the animal kingdom for 
defense as for attack. If it has been made use of above to 
explain the origin of visual ideas, so we have really antici- 
pated; the acquirement of a spatial image of the retina 
must precede this act in our consciousness of the body. By 
the fact that the perceiving cells of the optical projection 
field related to the retinal points are allied by association in 
different points of the motor-oculi projection field according 
to the retinal meridian, different grades of intensity of their 
excitement according to the distance from the centre of the 
retina, a firm orientation as to the position of the retinal 
points and thus a spatial image of the retina is gained. 
The process is the same as in the acquirement of optical 
memorial images; by coincidence or sequence of the excite- 
ment of adjacent retinal points arises the firm association C. Wernicke. 
40 
between the corresponding perceiving cells on the one hand, 
by the movements of adjustment of the eye between the 
latter and the points of the motor projection field on the 
other. By the constant recurrence of like relations under 
the same conditions, the associations gain the requisite sta- 
bility, even increased to insolubility. Evidently the con- 
sciousness must first be oriented as to the retina ere pro- 
jected images can be spatially estimated. 
As this consideration leads to the the spatial sense of 
the retina, in that the retina is considered as being a part 
of the surface of the body, while the optical apparatus of 
the eye combined with it only furnishes the equipment, so 
the like consideration applies to the tactile organ of the 
skin. In the skin a spatial sense can also be developed, 
in that the consciousness is informed as to the sequence 
and position of the sentient points of the skin. And this 
information can only be gained by the exercise of associ- 
ations between perceiving elements or perception cells, 
which correspond to the points of the skin, and mechanisms 
of movement in the motor projection fields of the trunk, 
eyes and limbs. But we will have to regard the latter as 
much more complicated than the combinations of move- 
ments of the eye muscles. Think how relatively simple 
are the movements of the eye-ball, contained in a given 
space, freely movable about a centre of rotation, in compar- 
ison to those of the more versatile tactile organ of the 
hand. If we only consider the simplest tactile movements, 
like flexion and extension of the fingers, we know from 
Duchenne, that they cannot occur without counter move- 
ments of the wrist joint, which evidently serve for its fix- 
ation against the forearm. The forearm must be fixed 
against the arm, and this against the shoulder, but the 
latter fixation presumes a corresponding innervation of the 
trunk muscles, without which the trunk would lose its equi- 
librium in using the hand. It is then a matter of acquiring 
definitely fixed relations between a large number of sepa- 
rate mechanisms of movement ere the hand can be used as 
a sense organ. This task seems so difficult that we might 
doubt the possibility of its accomplishment, if its appear- 
ance did not convince us to the contrary. 41 
Outline of Psychiatry in Clinical Lectures. 
Gentlemen, 1 cannot help seeing that in my statement 
the thought has occurred to you, it would be a more or 
less voluntary construction and will not stand the test of 
facts. Permit me to briefly mention the data which, as 1 
believe, necessitate the assertion submitted with convincing 
force. One fact is that in cortical diseases, be they of the 
occipital lobes, be they of the parietal lobes, continual 
defects are observed and in the first cases of the visual 
field, in the second of the cutaneous sensibility of the 
limbs. The occurrence of such defects incontestibly prove, 
in my opinion, that adjacent points in the retina must pos- 
sess a projection in adjacent cortical elements of the occip- 
ital lobe, adjacent parts in the skin of the limbs those in 
adjacent cortical elements of the parietal lobes. The occur- 
rence of circumscribed and hence continuous defects of this 
sort would otherwise be absolutely inexplainable. It is the 
next and most probable assumption that this projection 
refers to the nearest termination of projection fibres, the 
projection cells serving for perception. 
The second fact consists in the more certain orienta- 
tion we possess in regard to the retina and the whole cu- 
taneous surface. For the retina 1 need not now go into 
this. But the skin of the body is known to us at every 
point of the body with certainty, corresponding to the deli- 
cacy of the spatial sense. So it is that any person with 
closed eyes can immediately indicate the spot on the skin 
that has been touched. He cannot only name or indicate 
it with the finger, but he can also correctly turn his eyes 
to this spot. At the places with specially delicate spatial 
sense, e. g. the palm of the hand, he can reconstruct from 
the sequence of cutaneous points touched the form of a 
letter, a number, even arabesques, which have been outlined. 
Similar experiments succeed in the majority of persons at a 
number of other places on the skin. 
Gentlemen! If you have followed me thus far, you 
have acquired the most esseiitial material for the construc- 
tion of a consciousness of the body, but it is still imperfect 
and needs completion. The representation of three of the 
most important sense surfaces is still wanting, those which C. Wernicke. 
42 
serve for hearing, taste and smell. There is no difficulty in 
transferring the points of view gained to these senses. 
You will at least admit this of hearing, because here the 
sensory content of the sensation—think of the speech 
sounds—acquires an importance controlling the whole mental 
life. But yet we have seen in an example above, that 
under certain circumstances the organic sensation shows 
itself very forcibly in this sense and produces the compli- 
cated defense movement of recoil. Not only the intensity, 
but also the quality of the sense impression can cause sim- 
ilar effects; there are certain sounds which produce the 
feeling and movement of horror, and that tones are pleas- 
ant or unpleasant is a daily experience. Besides it is well 
known that a certain spatial sense is peculiar to the organ 
of hearing, in that the place is determined from whence 
the sensation of sound has come. It is shown to be more 
finely developed in pathological cases, but still presents cer- 
tain local signs which give the locality of the stimulus, are 
also present in the acoustic sense surfaces, excepting the 
arrangement of Corti’s organ, which serves for the orienta- 
tion of tonal quality. In taste and smell organic sensation 
and sensory content of the sensation are so closely united 
that they are only artificially separable. As you know 
they are both exquisite chemico-analytic senses, whose 
importance for the nutrition and protection of the organism 
is apparent. 
To the organic sensations belong the sensations coming 
from the muscles, joints and large viscera. These latter 
show very eclat that the organic sensations have an inde- 
pendent significance and may occur without modal sensa- 
tion. These organic sensations are only slightly conscious 
in health, although feelings of hunger and satiation, desire 
to urinate and defecate, sexual desires, etc., are known to 
everyone. Whereas diseases of the viscera prove that they 
are endowed with active sensibility and essentially contrib- 
ute to our feeling of well-being or discomfort. In fact it is 
this element which has always been differentiated as the 
“affective tone” of the sensations, i. e.t their attribute of 
being accompanied by agreeable or disagreeable feelings, in 43 
Outline of Psychiatry in Clinical Lectures. 
the organic sensations from the viscera predominating over 
all the others, even those which refer to the location of the 
sensations. 
The location of these visceral feelings is always vague, 
if definitely pronounced; think of the pains in the stomach, 
hepatic and renal colic, the discomfort of a distended blad- 
der, etc. But the normal functioning or the disordered func- 
tioning of these organs hence contribute largely to the gen- 
eral sensation, or in other words, the consciousness of the 
body is plainly dependent on the state of the large viscera. 
We will have to define in general the affective tone of the 
sensations as an affection of the consciousness of the body. 
It is therefore to be presumed that the consciousness of the 
body contains special projection fields for the large viscera, 
a presumption, which is essentially supported by certain 
hypochondriacal symptoms, which occur in the insane. In 
regard to the location of these projection fields we are 
wholly uninformed, if Meynert’s hypothesis is rejected, 
which places them in the ganglia of the corpora striata. As 
seductive as this may seem from general considerations of 
an anatomical and morphological sort, it is at present wholly 
undecided and permits no practical applications. 
The sum of the memorial images of all organic sensa- 
tions forms the content of the consciousness of the body, 
just as the memorial images of the modal sensations con- 
stitute the consciousness of the world. We may now 
undertake a psychological definition according to the points 
of view gained and state, that the first refer to the loca- 
tion of the stimulus, the latter to the form of the stimulus 
or the mutual arrangement of the stimulated elements. 
It is now possible to briefly state what constitutes the 
essential difference between a sense perception itself and its 
memorial image. The sense perception is always accom- 
panied by organic sensations and therefore definitely pro- 
jected into space, whereas the memorial image is not. Prob- 
ably it is the retinal points, skin points and directly asso- 
ciated “perception cells,” which produce the organic sen- 
sations. 
That all projection fields, which comprise the conscious- C. Wernicke. 
44 
ness of the body, must be regarded as the most intimately 
united with each other by association paths, I have already 
intimated. As the reports, which the body sends to the 
consciousness, are always identical under like conditions, so 
among the memorial images the organic sensations are more 
firmly united than can ever be thought of the memorial 
images of the world. The different parts of the body in 
their relations to each other are absolutely unchangeable, 
whereas the things of the world are proportionately change- 
able. We can more or less exclude the things of the 
world, whereas the sensations, which our body furnishes, 
accompany us continually. During sleep the effects of the 
world as good as leave no trace in us, whereas the surface 
of the body, on which we lie, continues to send its signals 
to the consciousness. Whatever position we may take while 
awake, we are unable to get rid of the constant effect of 
pressure and its perception on some part of the cutaneous 
surface. 
That a certain consciousness of the body constantly 
accompanies a person when awake, is incontestibly shown 
by his conduct. May the attention be ever so much taken 
with an object of the world, may one be ever so deeply 
absorbed in a view, in listening to a melody, the body still 
maintains its erect posture, continues to walk, avoids 
obstacles, adapts itself to the irregularities in the pavement, 
makes movements of defense of different kinds, etc. 
It is now comprehensible to us, that from each organic 
sensation the whole complex of memorial images of the 
bodily organs is called into consciousness, so that, if we 
hold to the analogy with the concepts of the consciousness 
of the world, here only a single large concept so to speak, 
that of the body, is constituted. At least those movements 
of defense, which we became acquainted with in intense 
organic sensation, indicate that almost all the muscles of 
the body can participate in it. For the formation of con- 
cepts of definite regions of the body, with as clear a boun- 
dary as in concepts of the world, do not seem to occur or 
imperfectly in the consciousness of the body. As a sense 
perception is impossible without the related organic sensa- 45 
Outline of Psychiatry in Clinical Lectures. 
tion, so the consciousness of the body is awakened in toto 
by each sense perception. Hence the consciousness of the 
body rises with every sense perception. 
Organic sensations have a double origin; besides the 
stimuli of the world there are internal stimuli, which 
produce them. Consider the skin’s feeling of warmth or 
cold in consequence of vasomotor processes, perverse sen- 
sations of taste in catarrh of the mucous membrane of the 
mouth, subjective noises in the so-called ringing in the 
ears, the flashes of light, which arise from the retina in 
absolute darkness, etc. All these organic sensations are 
not referred to the world. The opposite relation, which here 
exists, is then that sense perceptions are not thinkable 
without corresponding organic sensations, but that the latter 
may occur without the stimulus being referred to the world. 
The perception is preceded by organic sensation, the organic 
sensation not by the sense perception. So this idea is 
suggested from the state of the central projection fields, 
which 1 have already intimated, namely that the conscious- 
ness of the body is represented by the perception cells and 
indicates the first station in the cortex, which must be 
passed ere the sense stimulus reaches the consciousness of 
the world. The layer-like superposition of the ganglion 
cells of the cortex favors such an assumption, in which those 
of the medullary borders of the next layer (respectively adja- 
cent layers) would represent the consciousness of the body. 
There are certain times when the body of the adult 
undergoes marked changes, like that of maturity or puberty, 
the climacteric, pregnancy, the puerperal state and senile 
involution. According to our theory it cannot now seem 
strange that they afford a specially favorable foundation for 
the development of certain diseases of the consciousness; 
The relative stability of the consciousness of the body 
is explained, in that it seems as a sort of constant magni- 
tude in contrast to the other contents of consciousness, as 
a unity in comparison to the impressions of the world sub- 
ject to change. Besides the consciousness is taught by 
experience, that the body is inseparable, whereas the world 
is to be more or less divided into its components. So a C. Wernicke. 
46 
“primary I” (Meynert) is formed, by which must be under- 
stood the consciousness of the body. 
VI. 
CONCEPT OF SPONTANEOUS MOVEMENT. DIFFEREN- 
TIATION FROM THE REFLEX.. SENSATION AND IDEA 
OF POSITION, FEELINGS OF INNERVATION AND 
THEIR MEMORIAL IMAGES, SENSATION AND IDEA OF 
MOVEMENT ARISE FROM ORGANIC SENSATIONS. 
THE TACTILE SENSATIONS AND IDEAS OF THE TAC- 
TILE ORGAN OF THE HAND ARE DERIVED FROM 
ORGANIC SENSATIONS. 
Perhaps it has surprised you, that I have completely 
ignored a group of phenomena, which is most inti- 
mately related to the consciousness of the body, namely: 
all the phenomena of the motor apparatus. I have avoided 
this inquiry until now, because it is especially complicated. 
How is it conceivable that the mollusk, we have mentioned, 
learns to control the movements of its muscular apparatus so 
perfectly, as is actually the case, if we will set aside con- 
genital aptitude? We will now investigate this point more 
fully. 
It is well known that man, like every vertebrate, pre- 
sents the plainest evidences of his phylogenetic descent 
from invertebrates, in that the spinal cord has retained the 
organization according to the number of vertebrae. We 
must admit this metameric organization in each apparatus 
of movement, with which the brain is equipped. It thus 
indicates that primarily the reflex mechanism of the spinal 
cord is mutually related to the sensory and motor apparatus 
of like segments. So it is, that a slight prick to the 
palmer surface of the toes produces, as a reflex, their dorsal 
flexion. By the irradiation of the reflex demonstrated by 
Pfliiger it is certainly shown, that this metamereism does 
not exclusively fix the structure of the spinal cord, but 
that combinations of larger muscle areas, indeed according 
to the intensity of the stimulus almost all the muscles, 
must be prefigured in the gray matter of the spinal cord. 
All these reflexes have nothing to do with consciousness, 47 
Outline of Psychiatry in Clinical Lectures. 
in fact are congenital and occur later, when consciousness 
is precluded, as in profound sleep and unconsciousness. 
Still when awake consciousness subsequently takes note 
of them. The mollusk gets reports of the reflex movements 
depending on a congenital attribute of the body. We may 
call these reports sensafions of movement, without fore- 
stalling the qualifications, and their residual memorial 
images, ideas of movement or motor memorial images. 
We now see what we have to understand more strictly by 
sensations of movement. 
In a reflex movement a series of the most diverse 
sensations must arise. Chiefly those of the joint, which 
we may indicate .by g. This joint sensation, due to a 
definite excursion of movement, is combined with very 
definite cutaneous sensations h, for on the flexor surface of 
the joint the skin is shortened and approximated, while on 
the extensor stretched and separated. Therefore g has a 
very constant relation to h which occurs when the same 
position is passively imparted to the joint. But the mus- 
cles are also implicated, for in flexion they are contracted 
on the flexor side of the joint, lengthened and stretched 
on the extensor, while the opposite occurs in extension. 
It may be proven by pathological observations that these 
muscle sensations, m, have an independent meaning, for they 
are occasionally retained when the cutaneous and joint 
sensations are absent. The very definite relations of these 
three sensations to each other: g:h:m, we term the sense 
of position 1, so that l=g:h:m. 
We will call its memorial images ideas of position L. 
The same ideas of position must arise, when the joint is 
moved passively, so they by no means belong exclusively 
to the reflex act. 
A person’s ideas of position may be studied by pas- 
sively putting his joints in various positions. The normal 
person is either able to imitate these positions or to pre- 
cisely state each change, at least he shows he has a per- 
fectly correct idea of the position of his limbs. This 
experiment is especially important in the freely movable 
joints of the fingers and toes. A prerequisite for success is C. Wernicke. 
48 
the complete elimination of the individual’s own activity, 
or the elimination of his volitional impulse, which is not 
equally attainable in all individuals, for it presumes a cer- 
tain control over the movements. 
I 
Formerly the muscle sensations were wrongfully re- 
garded as the chief factor in the sense of position and 
therefore the possession of ideas of position were considered 
a special sense, the “muscle sense.” We will avoid using 
this term, for it may lead to further misconceptions. 
But if we now assume, the sense of position 1 is pro- 
duced by a reflex movement, the sensation of movement b 
arises; to those already mentioned a further characteristic 
must now be added, which can be nothing else than a 
sensation of cell action z, and is to be regarded as the 
cause of the muscle innervation at the moment of the 
reflex. By the muscle contractions, which then occur, 
certain muscle sensations ml are produced, and have a 
definitely constant relation to the process in the ganglion 
cells z> then ml:z• If we term the report, which comes to 
the consciousness from the motor impulse, the sense of 
innervation i, so i=z:ml. On the whole the sensation of 
movement b contains both components of the reflex move- 
ment, the sense of innervation as well as the sense of posi- 
tion, and these have, as is readily conceivable, a definitely 
fixed relation, then b—i:l. 
The muscle sensation ml is capable of direct demon- 
stration by faradization of the muscle. Yet at most it will 
then be possible to determine what current strength is 
perceived and whether changes in it are recognized. The 
resulting movement of the joint causes an independent 
sense of position, which is perceived like any other arising 
in the consciousness normally. A regular connection between 
the muscle sense and the sense of position does not exist 
in this experiment, because an isolated contraction of a muscle 
never occurs normally, so the conditions of the experiment 
offer a novelty to the consciousness. 
The sensations of movement, which reach the conscious- 
ness in this way and must evolve the ideas of movement 
B, by the contents constantly recurring in the same manner 47 
Outline of Psychiatry in Clinical Lectures. 
in fixed components of the consciousness, give only memorial 
images of reflex movements, but still very definitely appro- 
priate muscle arrangements are there represented, for reflex 
movements are without doubt co-ordinated as Duchenne 
thinks. According to Duchenne’s classification into impulsive, 
collateral and antagonistic muscle co-ordinations, the reflex 
movements come under the impulsive and collateral. The 
reflex movements are not without a certain adaptation, yet 
they are apparently to be regarded more as protective 
measures, which are to serve as a defense against irritation 
or to remove the part of the body from its range. These 
two factors are to be regarded as the most essential pre- 
liminary conditions for the accomplishment of spontaneous 
movements. Bear in mind, that during the reflex movement 
the consciousness is not only aware of the movements as 
such, but also of the sensation e, which is the stimulus 
exciting the reflex. Its memorial image E, be it tactile, be 
it directly painful irritation, will consequently be associated 
with the idea of movement B. We can then only speak of 
spontaneous movements, when the memorial image E produces 
in the association path EB the idea of movement B, that the 
movement actually happens. Likewise as a preliminary 
condition the assumption is essential, that a centrifugal path 
p extends from B to those ganglion cells which have 
previously participated in the reflex process. This path is in 
fact proven to be the pyramidal tract. Two examples 
will better illustrate the essential difference between reflex 
and spontaneous movements. A pin prick to the sole of the 
foot results, as a reflex movement, in a flexion of the lower 
extremity in all its three joints, and thus the foot is 
removed from the irritation. In the spontaneous movement 
the pin is merely seen, the memorial image E of the tactile 
sensation e becomes conscious and through the association 
path EB effects the movement, which had previously been 
reflex. The necessary path B% is the pyramidal tract. The 
closure of the eye on the approach of a foreign body is very 
similar in its nature; then an optical perception occurs first, 
which is associated with the memorial image E, as the 
latter with the idea of movement B. In a general way we C. Wernicke. 
48 
may define spontaneous movements to be reactions to mem- 
orial images of external stimuli. The majority of spontane- 
ous movements during life might really start from some 
external stimuli, if the possibility cannot be controverted, 
that present external stimuli may be wholly wanting, so 
that spontaneous memorial images form the starting-point 
of the association process, which finally ends in the move- 
ment. 
The child's first spontaneous movements are apparently 
controlled by organic sensations. The movement of sucking, 
which is reflex in the new-born, subsequently becomes a 
spontaneous movement due to the organic feeling of hunger. 
Later the sight of the nipple suffices to produce the move- 
ment of sucking. The sensitiveness of the child’s eye to 
bright light refers to the predominant organic feeling as the 
cause of closing the lids. Of the spontaneous movements 
those of defense are by far the most prevalent in the early 
months, i.e., those depending on organic sensations and are 
a more or less faithful imitation of the reflex movement. 
Also very complicated combinations of movement clinging to 
the adult through life, like those of shrinking, recoil, spring- 
ing aside, etc., are under the control of organic sensations, 
as shown by previous examples, and if heredity is admitted 
to have a certain influence in the development of language, 
which can hardly be denied, then the impulse to imitate 
sounds heard have to be referred to organic sensations in 
the acustic. In other words, it will have to be assumed 
that the excitations of the acustic at a certain period of life 
are attended with a pleasant feeling, and that the child’s 
experience in being able to utter these sounds is utilized 
to produce these pleasant sensations by its own speech 
movements. Organic feelings in the optical domain are 
demonstrated in the adult, when the pleasant sensation, 
similar to sensual gratification, is considered in the play of 
colors, where those of different saturation follow each other 
in rapid succession. That in the province of the acustic the 
pleasure afforded us by a piece of music originally depends 
on the same condition, can scarcely be doubted. 
The simplest scheme of a spontaneous movement, which 49 
Outline of Psychiatry in Clinical Lectures. 
was given above, may be presently applied to the actively 
acquired tactile ideas. As in the reflex the movement 
follows the stimulus, as in the movement of defense the 
optical perception of the approaching object causes the lids 
to close through the association path, so doubtless the 
optical perception of an object is often the starting-point for 
the execution of tactile movements—movements of offense 
according to Meynert. If the whole surface of our skin 
functionates as a passive tactile organ, i.e., imparts certain 
vaigue tactile perceptions, which occur without any move- 
ment of the body, we are still in possession of specific 
movable tactile organs, real antenna, so to speak: the 
extremities and in early life the mouth. The child feels of 
bvery object it sees with its hands and mouth. The previous 
statement as the retina, that the memorial image is the resi- 
dence of a definite spatial arrangement of the excited retinal 
elements,must naturally apply to the passive tactile organ. In 
the retina there is to be sure a place of keenest vision,which 
we then claimed to be the place serving exclusively for 
the acquirement of memorial images. In the passive tactile 
organ of the skin there are also areas of keenest sensation, 
to which belong the mouth of the suckling, as well as the 
skin of the hands and fingers; but still the assumption 
might be advanced, that no single limited cutaneous area 
alone gives origin to memorial images, but that they may 
be acquired from every part of the skin. Within certain 
limits this is also true of the retina of course, for objects 
perceived eccentrically are correctly recognized under certain 
conditions, and for the retina it may be postulated, that 
the memorial images thus acquired are gradually associated 
\vith those of central vision. A similar association between 
the memorial images of the different cutaneous surfaces will 
have to be presumed in the central projection surfaces of 
the passive tactile organ, whenever they are derived from 
the same object. But still it cannot be denied that finer 
tactile ideas are largely acquired by the movable tactile organs: 
the hands and fingers. The way this occurs will now be 
more closely investigated. 
Should a concrete thing, e. g., a penknife, be felt of, C. Wernicke. 
50 
and we assume this is done with one hand only, the volar 
surfaces of the fingers are passed over it, being frequently 
removed, and so convince ourselves of its consistency, 
smoothness or roughness, temperature of the surfaces and 
the general form and size of the object. We must regard 
the sum of these sensations to be a unit, which only recurs 
when a penknife is again felt of, but from no other concrete 
object. If we call this unit the tactile sensation of an 
object /, it is composed of a series of cutaneous sensations 
el+e2+e3... and a series of sensations of motion bl+b2+ 
b3..., which have a simple and complicated relation with 
the first. Simple, in that any greater muscular contraction 
intensifies the sensation of pressure, which is produced by 
the object, complicated in that a series of successive move- 
ments is required to ascertain the form of the object under 
conditions of equal pressure. How complicated the quantity 
t=e+b must appear to us, arises from the fact that each 
member of the series bl+b2 is already a compound quantity, 
as 1 have just shown. If we bear in mind that b=i:lyi.e., 
indicates a definite relation of sense of position and feeling 
of innervation, so now the association with the passive 
tactile sensations of the series el+e2... is added. This 
complicated quantity we may term the tactile sensation t 
of an object. We name its memorial image T tactile idea 
or tactile image. In fact we test the presence of tactile 
ideas by undertaking to recognize concrete objects by merely 
touching them with the hand, the eyes being closed. The 
normal person is able to do this readily with any object 
familiar to him. 
By going further into our subject it ought to be clear 
to you what an important role the movements of the body 
play in sense perceptions. The memoral images of the 
tactile sense, which in the beginning of our researches we 
traced to a sort of passive projection process, like the 
other sense perceptions, now seem composed of memorial 
images of spontaneous movements. But as these motor 
memorial images will have to be added to the conscious- 
ness of the body, we then enter a province, where con- 
sciousness of the world and the body lose their principal 51 
Outline of Psychiatry in Clinical Lectures. 
contrast and the proposition that changes of the body alone 
inform us of the things of the world, is again most evidently 
verified. All the spontaneous movements, which serve to 
master the world (offensive movement, Meynert), show the 
same connection between the world and body. Every ac- 
complishment or art within the scope of movement must be 
tediously learned, from those of walking and speaking to 
the most complicated of the creative artist. All these 
movements take place under constant direction of the tactile 
feeling, they are first possible by the fixed possession of a 
large series of the most complicated tactile ideas. When 
we undertake to test the ideas of movement, we generally 
content ourselves with the simplest evidence of manual 
dexterity. The patient, with eyes closed, is asked e. g., 
to unbutton and button his coat, to sharpen a lead pencil, 
to take out his watch, to outline figures in the air, or to 
write in the usual way. With few exceptions the manip- 
ulation of one or more objects is always requisite, there- 
fore the possession of tactile ideas is indispensable for the 
performance of the required movements. 
As in the tactile ideas just discussed the movements 
are united with cutaneous sensations, so there is a specially- 
complicated muscular apparatus, whose movements are 
under the direction of retinal impressions. When the form 
of an object is to be accurately perceived, by suitable move- 
ments of the eyes, the place of keenest vision, so to speak, 
is passed over the outlines of the object, a process which 
is perfectly analogous to feeling it by the movable tactile 
organ of the finger, and could well be called feeling the 
contours by the macula lutae. The complicated eye 
movements, which are requisite, leave motor memorial 
images and form very similar series of associations as to 
those acquired in feeling with the hand. As these blended 
with the passively acquired memorial images from cutaneous 
sensations E represent the complete tactile idea of an 
object, so the motor memorial images of these eye move- 
ments are a new component, which, associated with those 
already known constitute that which may with propriety 
be termed the visual idea. Unfortunately it is impossible C. Wernicke. 
52 
to separately investigate the sensations and ideas of position 
of the eye movements. Nevertheless their importance with 
respect to orientation in space cannot readily be overesti- 
mated, for they are another eclat example of how organic 
sensations are utilized to gain in consciousness a fixed 
image of the world. In conclusion I must call your atten- 
tion to a very similar relation between speech movements 
and perceptions of hearing; the child’s speech move- 
ments are chiefly feeling movements but which are not 
related to the cutaneous or retinal sensations, but to those 
of hearing, i. e. are directed by them. 
In so far as we may survey the content of conscious- 
ness, it shows itself accessible of a certain localization by 
the fact of projection. As the optical memorial images are 
localized in the central projection field of the optic nerve, 
the acustic in the central projection field of the acustic, we 
cannot doubt that tactile ideas from concrete objects are 
similarly localized. Simple figures, like numbers, a cross, a 
circle, a triangle, placed on the skin, are recognized by 
feeling, when the eyes are closed. The central pro- 
jection of the passive cutaneous tactile organ then develops 
a spatial sense, like the retina, in which the mutual 
arrangement of the cutaneous surfaces affected by the 
stimulus is decisive for the memorial images thus arising. 
As above stated, these cutaneous memorial images 
become tactile ideas by their association with the ideas 
of movement of the tactile organs. 
Hence the same tactile images reach different projection 
fields, and are not only united with each other by fixed 
association, but particularly with corresponding visual ideas. 
The tactile ideas of concrete things should be exclusively 
localized in the arm regions, and of course for the right 
and left arm in different hemispheres, because these tactile 
ideas in the adult at least are wholly acquired from move- 
ments of the hand. 
It is comprehensible, that we are not congenitally 
orientated as to the position of retinal points, but must 
acquire it. Orientation as to up and down, right and left, 
relates exclusively to the body and simply indicates the 53 
Outline of Psychiatry in Clinical Lectures. 
acquirement of fixed associations between the perception 
cells, which are co-ordinated to the points of the retina, 
and the “concept” (see above) of the body. Therefore 
sensations of movement of two kinds are to be considered; just 
those derived from movement of vision upward, downward, 
right and left. They may be called general eye movements. 
Second, those serving to focus the eye ball to the light 
stimulus or to close it, may be distinguished as movements 
of adjustment. That eye movements are reflex at some 
period of the individual’s life is an absolute physiological 
postulate. Most probably there are movements of adjust- 
ments of adjustment, which may be produced by means of 
suitably formed combinations of the primary optical centres 
with the nuclei of the eye muscles by the light stimulus. 
The feelings of the innervation (i=z:ml, see above) origi- 
nating jfi this way, presume a specially fine sensibility of 
the eye muscles, in case special sensations of position of 
the eye ball (ciliary nerves?) will not be admitted. Their 
memorial images are the ideas of movement in the province 
of the eye muscles and are associated in accordance with 
their mode of acquirement with the perceiving elements in 
the projection field of the retina, that from some of these 
a definite form and a definite degree (range of excursion) 
of associated muscular combinations can be produced. 
The points of stimulation found by Munk in the dog’s 
occipital lobes, by which movements of adjustment could be 
effected, apparently correspond to these. In the dog they 
locally coincide with the cortical projection of the rectina, 
and the centrifugal fibres B% (see above) arising from them, 
run in common with the projection fibres in the sagittal 
medullary fasciculus of the occipital lobe. In so far they 
takb an exceptional position and are distinguished from the 
fibres of the pyramidal tract. 
VII. 
CONSCIOUSNESS OF PERSONALITY OR INDIVIDUALITY. 
IS ITS LOCALIZATION POSSIBLE? THE EN- 
IGMA OF SELF-CONSCIOUSNESS. 
The cursory glance 1 have given you of the two great C. Wernicke. 
54 
provinces of consciousness of the world and body, far from 
exhausts the content of consciousness, for they are but the 
first foundations of a consciousness, we have in common 
with animals, if quantitatively different. Man’s higher 
mental development must surely start from these foundations* 
but far surpasses them, and begins, so to speak, at the 
time these foundations are required. The results of the 
normal mental development is the formation of a personality 
or individuality. The unconscious person, whom we have 
chosen as an example, must regain consciousness of his 
personality, ere we can regard him as entirely himself, i.e., 
he must remember, not only that he has the same body as 
before the accident, but that his mental possessions are the 
same. The consciousness of the personality, which we, must 
now investigate somewhat minutely, presumes the possibility 
of an ego development. Its chief condition is, as we have 
seen, the unchangeable body in contrast to the changeable 
world. The force of this fact is evident the moment the 
child begins to use the word 1. If the mental development 
is arrested before this period, an idiot occurs, who speaks 
of himself in the third person. The consciousness of the 
personality embraces all that is generally understood by 
mental possession and mental attainment, all the child must 
be taught by education, development and training, therefore 
the- individual may be formed by it. 
Primarily decisive for a person’s future is doubtless the 
social medium, in which he grows up. A living example is 
always the most effectual means of education, and must be 
the more so, when combined with self-evident authority, 
which is innate in the parents toward the child. The 
parents’ family life undoubtedly imprints the decisive stamp 
on the child/as to its mental personality, its future char- 
acter. The consciousness of the personality therefore em- 
braces all those attributes, which follow with instinctive 
legitimacy from the social medium, in which the individual 
has grown up and lives. They are especially the so-called 
attributes of character, which are very definitely developed 
by the force of this medium, consequently a brutal or refined 
affective condition accordingly as an egotistic or altruistic 55 
Outline of Psychiatry in Clinical Lectures. 
bias for future actions predominates. These attributes may 
be developed to a marked degree, if the most powerful and 
likewise half instinctive means of the person’s education, 
phonetic speech, does not cooperate, as the example of the 
deaf mute teaches. 
The possession of language must be associated to the 
consciousness of the personality in a certain sense, in so 
far as it reflects the peculiarities of the medium, in which 
the person has lived. The variation of language in different 
peoples assigns a special position to this part of the mental 
possessions, different from that which the universally ap- 
proximative like consciousness of the world and the body 
occupies. Within one and the same race there are variations 
in dialect, which often cling to a person his whole life and 
betray the medium in which he has lived. The person’s 
manner of speech, which differs so much according to his 
education and degree of mental development, belongs to the 
consciousness of the personality as a partial phenomenon. 
By language the whole mental status of the adult, and not 
only of that, but of countless generations, whose mental 
inheritance we have received in language, is transmitted in 
definitely logical arrangement and organization to the child’s 
brain, somewhat comparable to the action of an uncompleted 
instrument. Systematic, logical thought, all finer mental 
operations doubtless have their main root in the perfectly 
transmitted art of language. Therefore the kind of language 
which has come to the individual from his parents, is deci- 
sive as to his whole mode of thinking, whether crude and 
inadequate, as from persons of low rank, or from refined 
and highly educated parents. The altered mode of speak- 
ing in the insane indicates a change in the mental person- 
ality. If we leave out of consideration the educational me- 
dium of language, so all that the person learns by instruc- 
tion and tradition, ihe sum of knowledge, which he appropri- 
ates, becomes a component of his personality. When we 
speak of a person’s memory, we usually understand the 
sum of his acquired knowledge, at least we generally 
test the memory by asking about this information, 
and judge of the ability to remember according to the C. Wernicke. 
56 
average established by the majority of .normal indi- 
viduals. The sum of this information or knowledge is not 
only quantitatively, but also qualitatively manifested differ- 
ently, according to the individual’s course of development. 
1 need not go further with you into the quantitative differ- 
ence. It is therefore qualitatively so great, because the 
knowledge of the lower grades of education consists in most 
part of serial associations, which dispense with inner con- 
nection; historical dates, sayings and songs learned by 
heart, the Ten Commandments, even the multiplication 
table are remembered. So long as new facts are acquired, 
a sort of summation of this possession occurs in knowledge, 
but which is not wholly equally equivalent, in so far as the 
child’s brain is characterized by the ability to retain what 
is learned, the early acquired knowledge is often refreshed 
and so must become fixed in the memory by its use. 
Reading and writing usually belong to the information 
acquired at this time, which are well fixed, but still based 
on acquired association of forms of letters with phonetic 
speech, an association, which is often strangely broken 
through by focal brain diseases. 
To the consciousness of the personality also belongs 
the sum of experiences peculiar to the individual. The 
individual, whom we have before us, always represents 
their sum total, be it information, be it experience, a sum, 
which has a positive value only at a certain instant of time, 
but which gains new accretions every hour, every day. 
The present state of the brain in a certain measure is the 
derivative of all prior states. Consequently the requirement, 
which must be made of an individual after a mental dis- 
ease, that he recognize the morbidness of his prior state; 
for the sum must necessarily be false, if false components 
are contained in it. 
The range of a person’s interests, be they merely 
egotistic, or in-others, family, etc., or fixed on the occupa- 
tion, the daily work, also belong to the consciousness of the 
personality. The interest in family, friends, chiefly to the 
depreciation of self, often takes a dominating position in the 
individual’s content of consciousness, think of the intimate 57 
Outline of Psychiatry in Clinical Lectures. 
relations between mother and child, between man and wo- 
man in sexual love, etc. The readiness to die for others, 
as well as on the one hand to die for an idea, a principle, 
a set purpose, on the other the predominant general egotism 
of the majority, shows the extreme opposites and the infin- 
itely large variety of mental personalities, all of which are 
within the normal. Further variations are induced by dis- 
ease. All this explains the difficulty of establishing a 
psychical status, be it in the normal person, be it in one 
mentally diseased, it therefore also explains the slow ad- 
vancement of clinical psychiatry. 
The consciousness of the personality has a certain, 
readily evident dependence on the consciousness of the body 
and the world. The person with keen senses and robust 
health must develop differently in his mental personality, 
than one with blunt senses and feeble body. The character 
attributes of courage or cowardice, frankness or secrecy, to 
act vigorously or timidly, may often be traced to such 
foundations in the consciousness of the body and the world. 
The possibility of adaptation to surroundings, which Herbert 
Spencer calls the sign of the normal mental state, varies 
according to these preliminary conditions. The mutual rela- 
tion may be expressed in the proposition: The consciousness 
of the personality is a function of the consciousness 
of the world and the body. But if the impressions 
derived from the social medium are included in the 
consciousness of the world, which is proper, this prop- 
osition is very obvious. It is then evident that under good 
conditions such personalities will develop, whereas in crim- 
inal families anti-social personalities occur, and a morbid 
mental state alone does not suffice to explain the criminal 
nature, but rather such' can only be spoken of, when the 
mental personality has developed contrary to the surround- 
ing medium, as in cases of so-called moral insanity. At any 
rate the consciousness of the personality in comparison to 
the consciousness of the world and the body is by far the 
most complicated, because depending on such association C. Wernicke. 
58 
processes, to which previously a certain individual variation 
was inherent. 
The position the individual believes he occupies in 
human society according to his own estimation, depends on 
the consciousness of the personality. If it is morbid, we 
find the striking symptoms of grandiose delirium, micromania, 
delusions of persecution, personal importance, hypochondria, 
etc. We will later go into these morbid phenomena more 
fully. 
What spatial idea can we gain of the consciousness of 
the personality? Or have we reached the limits of spatial 
conception and now face the incomprehensible? 
Evidently the consciousness of the body is usually cap- 
able of localization, because it is most closely united to the 
standard of the projection system. The consciousness of 
the world at least permits division according to the projec- 
tion fields in which its components, the sensory memorial 
images, must be regarded as stored. In the consciousness 
of the personality a localization according to the standard of 
the projection system is now out of the question. Therefore 
is it entirely beyond the range of the principle of localiza- 
tion ? 
That thjs is not the case, clinical experience teaches, 
for certain mental diseases exclusively affect the conscious- 
ness of the personality, others almost entirely the con- 
sciousness of the world or body, finally again certain other 
diseases of the personality are combined with those of the 
body or the world. The disease process therefore seems 
distributed to different localities. The progressive and per- 
nicious mental disease, progressive paresis, successively 
affects the consciousness of the personality, the world and 
the body and seems to begin quite regularly in an atrophy 
of the fibres of the outermost gray cortical layers. Further 
clinical experiences exist and indicate an extensive localiza- 
tion within the consciousness of the personality. In conse- 
quence of severe diseases, also of brain diseases, very large 
portions of the consciousness of the personality are extin- 
guished. Fancy, that all those ideas acquired very recently 
—during a period, which may embrace a few months or 59 
0 lit line of Psychiatry in Clinical Lectures. 
years, as well as half a life time, are lost. Cases of this 
kind have been reported, e.g., from my clinic by Dr. Freund, 
under the caption of general weakness of memory.* These 
persons have quite an accurate memory—sometimes as 
accurate as could be expected of them normally—of all events 
prior to a definite period, e.g., the 30th year, while all those 
subsequent have disappeared from their memory, often their 
most important experiences, such as marriage, birth of 
children, loss of property, etc.; also well-known public 
events, accomplishments acquired during the time, etc. 
The loss embraces, in a word, all those links in a chain of 
ideas, which have been added to the consciousness of the 
personality from a certain period. Consequently such a 
person, if an old woman, still considers herself a young 
girl and so acts in comical contrast to the reality. To a 
less degree the same memory defect is almost physiological 
in very old people, when early memories may be faithfully 
retained, while the daily occurrences of the past few days, 
weeks, months are often entirely lost. The fact, that the 
ideas of a definite period are lost and in consequence of 
gross material disease, admits of the immediate interpreta- 
tion, that the location in the cortex of these complicated 
remembrances is determined by the time of their acquire- 
ment, from which, as the crudest, but immediate sequence, 
it would follow, that a sort of layer-like deposit of ideas 
occurs in the brain, similarly to the formation of the earth’s 
strata. One might be inclined to ascribe the consciousness 
of the personality, as the latest formation, to the outermost 
cortical layer composed of projection fibres. Without being 
frightened by the materiality of this view, there are other 
data, which stand in the way of using the facts previously 
mentioned for the assumption of a layer-like localization. 
For instance, a circumscribed loss of recently acquired 
memorial images is repeatedly observed in focal diseases of 
the brain. Cases are known and sufficiently authenticated, 
where after apoplexy, persons, who had command of several 
languages, lost this accomplishment, except their mother 
tongue. Charcot has recently reported such a case. Un- 
* Arch. f. Psych 20 Bd. S. 441. C. Wernicke. 
60 
fortunately the difference between the ability to speak and 
to understand a language has not been sufficiently studied, 
so that the location of the loss of function in the strictest 
sense is impossible. Still the facts reported show with cer- 
tainty that this loss is perfectly analogous to the other focal 
brain symptoms. If we now assume that it is a matter of 
a purely motor defect, which, according to all our previous 
knowledge, would have to be located in Broca’s convolution, 
so in consequence of our above assumption, apoplexy com- 
pletely destroys very definite layers of this convolution, sit- 
uated close above or below, while the mother tongue would 
be left wholly unprovided for. This assumption seems 
extremely improbable. Whereas the following idea has in 
its favor a large number of other well known facts. The 
cells and fibres of the cortex are extremely delicate struc- 
tures, which in a certain measure remain in an embryolog- 
ical state so long as they do not functionate. Through 
function they attain a certain resistance and this increases 
proportionately to the exercise of the function. This 
hypothesis is exactly analogous to Cohnheim’s for the 
muscles, in that they can only grow and increase during 
their function. We now assume, that in the vicinity of a 
nodal point in the brain, there is a centre, like Broca’s con- 
volution, where besides cells and fibres, which have long 
functionated and therefore possess a certain resistance, 
there are those whose nutrition is impaired by slight inju- 
ries. Thus it seems perfectly plausible, that the collateral 
effect of an acute focal disease extends to the adjacent 
areas to destroy the one element, while it leaves the others 
intact. This hypothesis serves to similarly explain cases of 
general weakness of memory. As here in a circumscribed 
place, so there an injury implicating the whole brain mantle 
must be assumed, which only the resistant elements could 
withstand, and so it is not strange if the degree of this 
resistance is a function of time, in other words, only those 
memorial images disappear, which are of a relatively short 
duration. 
The consciousness of the personality includes one of 
the highest functions of the brain, which has always 61 
Outline of Psychiatry in Clinical Lectures. 
been the enigma of all enigmas, the phenomenon of self- 
consciousness. In this phenomenon it looks as if the same 
organ, the brain, which is believed to be able to perceive, 
would at the same time be the thing perceived. But it is 
impossible for one and the same thing or being, which per- 
ceives, to also be the object of perception. This inconsist- 
ency shows what vagueness prevails among philosophers as 
to the nature of the matter in question, who still think 
they should here admonish against overestimating the import 
of certain anatomically physiological opinions. Reflect, that 
the consciousness of the personality may be regarded as a 
sum, whose value is a function of time, then that the per- 
ceiving individual at the moment of the perception is a def- 
inite mental personality, which differs from that of the 
moment before by an appreciable value, so it cannot be 
surprising, that this last value is able to perceive besides 
the matter of the sensory perception the value of that sum 
preceding it in point of time. In other words, the mental 
personality does not perceive itself, but the personality of a 
few moments, hours, days or years before, and it is a delu- 
sion to believe it has remained exactly the same. THE 
Alienist and Neurologist. 
VOL. XX. 
ST. LOUIS, OCTOBER, 1899. 
No. 4. 
OUTLINE OF PSYCHIATRY IN CLINICAL 
LECTURES.* 
PS YCHO-PH YSIOLOGICAL INTRODUCTION. 
DR. C. WERNICKE, 
Professor in Breslau. 
VIII. 
the action of consciousness depends on the 
CONTENT OF CONSCIOUSNESS. PREFORMED ORDER 
OF THOUGHT CONNECTIONS. NARROWNESS OF 
CONSCIOUSNESS. DEGREE OF CONSCIOUSNESS, AT- 
TENTION AND WILL. ABILITY TO ATTEND. AFFECTS. 
NORMAL QUANTIVALENCE OF IDEAS. 
We will glance back over the path we have come. 
The organ of consciousness is now shown to be populated 
by a sum of potential energies, the memorial images and 
their various groupings, from the simplest to the complex, 
for which the term remembrances seems adapted. The 
natural classification of this content of consciousness into 
the three divisions of the world, body and personality has 
been given, a classification, which, as we will see later, is 
*Translated by Dr. W. Alfred McCorn, Resident Physician “River Crest,’’ Astoria, L. 
I., New York City. 65 
Outline of Psychiatry in Clinical Lectures. 
required for the practical observation of patients. But 
observe, that in this, as it were, inactive consciousness 
you have an inanimate machine. It will now be our pur- 
pose to consider more fully the action, which occurs in the 
organ of consciousness thus constituted. But we must 
maintain, that this organ is exclusively composed of nerve 
fibres and ganglion cells, that we then can only require of 
it the course of certain processes of excitement and in its 
diseases a morbid change in these processes of excitement. 
What we had previously considered, had no other premises, 
for the content of consciousness, the sum of all the acquired 
ideas had for us no other meaning than a permanent mole- 
cular change in definitely organized fibre and cell masses 
in consequence of processes of excitement having -occurred. 
The capacity of nervous elements to be permanently changed 
by past stimuli, we called memory, a phenomenon which 
has its counterpart in inanimate nature in the magnetization 
of iron. We then have to deal with existing processes of 
excitement in a complicated organ whose action definitely 
depends on prior processes of excitement, and next have to 
investigate in what way this dependence is manifested. 
If we ask a question of a person about some science, 
with which lie is unfamiliar, the sense of the question is 
not comprehended. No one will be astonished, and yet 
this example proves the fundamental proposition, that any 
new possession of ideas, here the comprehension of the 
question, can only be attained by the presumption of the 
present possession being definitely constituted. We 'desig- 
nate this process, occurring at the time in the consciousness, 
thought, the idea excited by the question the initial idea, 
and the result of thought, which is contained in the answer, 
the terminal idea, so in the ,above example thought did not 
occur, because the proper initial idea was not in the indi- 
vidual’s possession. Hence if we maintain, that thought as 
a rule follows an external stimulus, some sense perception, 
it then very gradually seems necessary that the sense 
perception be understood. A sense perception, which lias 
never occurred before, does not therefore follow the usual C. Wernicke. 
66 
course of a definite thought; for it is not only uncompre- 
hended, but very imperfectly received, as anyone may 
observe when listening to the sounds of a foreign language. 
The perception then presumes, for it to be perfect, a definite 
mental possession. Very similar to this simple example of 
thought is it with the more complicated processes of thinking, 
in which the initial idea is often a very ordinary sense 
impression and may therefore escape our attention. These 
more complicated processes of thinking are generally carried 
on in previously worn paths, hence the comparative rarity 
of really new thoughts. Thought is universally dependent 
on a possession of ideas long acquired and definitely ar- 
ranged, in other words, it is generally a mere repetition of 
the same processes of excitement in the same arrangement 
as they have repeatedly occurred. 
On what does this arrangement dominant in our ideas 
depend, which is manifested in normal thought? As you 
recollect, we called the union of ideas association, the 
arrangement dominant in the ideas may then lead us to 
conclude the possession of definite associations, which are 
approximately the same in all individuals. Our question 
then will be: In what way are these associations generally 
present formed? In part 1 may add what has already been 
said and is familiar to you. In speaking of the conscious- 
ness of the world 1 have already called attention to the 
fact, that in a certain measure the natural arrangement and 
sequence of things are reflected in our brain, and thus a 
regular union of definite phenomena with each other occurs 
in our consciousness, as furnished by the world. To the 
attributes of things, which we have found to be quite con- 
stant and little changeable, belong also their relations to other 
things,be they animate, be they inanimate, and particularly to 
our person. That ice comes from water when it is frozen, and 
steam when it is boiled,'is an experience, which we consider 
regular, owing to its constant occurrence. It is thus reflected 
in our brain that an association between the ideas of water, 
ice, steam, cold and hot occurs in a definite order. The 
sensation of cold to the skin can awaken the idea by 67 
Outline of Psychiatry in Clinical Lectures 
association that the water is freezing. The association is 
somewhat complex when the observation of the thermome- 
ter leads to the same conclusion. Here an optical percep- 
tion is the initial idea and the association with other ideas 
learned. If the simplest phenomena of nature are forced 
upon us in their regular order, so it is the same with 
the more complex combinations of ideas, which we learn by 
the example of our surroundings. The congenital desire for 
food is analogous to the impulse with which the phenomena of 
nature are forced upon our brain. If we have always been in 
the habit’of behaving the same as others in like position, so 
one learns by the crudest senses from the example of others, 
that potatoes are dug and cooked to satisfy hunger, then 
the simplest example is sufficient, that the potatoes must 
be planted to appease hunger later, where the planting of 
the potatoes is the terminal idea of a very complex action, 
which is finally produced by the initial idea of hunger, 
after the interpolation of a whole series of associations. In 
the simplest relations all action is governed by 
from the surroundings. The medium, in which a person 
grows up and lives, suffices to fill the consciousness with a 
whole series of ideas in a definite order, and the more 
monotonous the life, the more fixed and unchangeable is 
this order of ideas, undisturbed by the variety of compli- 
cated conditions of life. The focal consciousness, that one 
has to behave like others, is frequently active when 
thought, in consequence of mental disease, is wholly pre- 
verse: the uncontrollable and resistive patient is often ren- 
dered tractable by the example of his fellows. The entire 
institutional treatment of the insane rests on this principle. 
On the other hand how thoroughly innate the focal con- 
sciousness is in us, may be learned, when in a crowd one 
participates in some general demonstration with the inten- 
tion of remaining passive, yet becomes active through the 
feeling the crowd inspires. The untutored deaf mute may 
be instructed by example. If no other defect exists, such a 
person often becomes a useful member of society within a 
certain narrow sphere of life. C. Wernicke. 
68 
Articulate language is still the chief means for the ac- 
quirement of definite order in the ideas. It readily estab- 
lishes the finer and more exact relation, not only between 
the concepts of concrete objects, but between these and 
the results of actions, arrange the latter in point of time 
and distinguish by fine shading the position of the active 
personality. For definite complex associations, the abstract 
concepts, which are first made known to us in part by 
language, suggest abbreviating terms, so that we learn to 
use whole series of ideas, and by such abbreviations des- 
ignate 'definite states of the personality, which everyone 
is acquainted with empirically, like love, hatred, fear, 
anxiety, hope, solicitude, etc. In such expressions a whole 
series of occurrences are at our command in a sort of com- 
bination, which is comparable to the concept of concrete 
objects. The structure of sentences, their logical organiza- 
tion gradually results that we think according to their di- 
rection. This at least chiefly differentiates the educated 
from the uneducated person, for the first is able to use 
every logical shade of expression. 
What 1 have just said needs further elaboration; you 
might readily fancy 1 would identify language and thought. 
I am far from it, but would merely call attention to the- 
fact, that for the comprehension of language not only famili- 
arity with that spoken, but also the possession of the same 
ideas as the speakers, is an indispensable presumption. We 
then assume a certain uniformity of mental personalities, 
while heretofore we have placed their individual variations, 
in the foreground. And there is no mistake that the trans- 
mitted possession, which we have retained in language by 
the construction of sentences and the terms for abstract 
concepts, is chiefly to blame. In all variation of the social 
medium the epoch, in which we live, still conditions for all 
normal individuals a definite possession of identical com- 
binations of thought, hence in this respect it is necessary 
to caution against overestimating the variation of individuals. 
For psychiatry this is certainly a favorable factor, which 
facilitates clinical observation. 69 
Out line of Psychiatry in Clinical Lectures. 
The question is often argued, whether thought occurs 
chiefly in words, and how far it depends on them. Many 
teachers have favored such a dependence and cited the ab- 
stract concepts as evidence, that coordinated thought cannot 
dispense with the abbreviations contained in language. But 
these abstractions are in great part merely the means of 
communication, and it is to me incomprehensible how any- 
one, who accepts the present theory of aphasic states, can 
think that a person with total aphasia has lost the concept 
of faith, love, hope, of fear, anguish, hatred, sorrow, solic- 
itude, etc., or of state, society, religion, time and space. 
The patient’s conduct does not indicate it. As much as 
may the word be associated with a whole series of ideas, 
still the decisive factor is not the association with the words, 
but the association of these series of concepts with each 
other, may it have first been acquired by the word. Lan- 
guage is merely the means of adjustment, the task-master, 
by means of which of the idea the ideas are forever 
arranged in series. 
What we have above designated as thought, is well 
illustrated by the process, which Fechner has called psy- 
chophysical movement. This psychophysical movement has 
been compared by Fechner to the course of a wave of ex- 
citement, which we may regard as occurring between the 
initial and terminal ideas. It is evident that we thus 
transfer the view we had of the course of the process of 
excitement in a definite nerve area to a whole system of 
fibres and ganglion cells continuous with each other, and as 
continuous as are the various early acquired associations. 
The error is the same as though we compared the move- 
ment of a wheel to that of the whole machine, yet in both 
cases it is a matter of similar processes of movement. If 
we suppose, for illustration, the curve of the process of ex- 
citement is drawn upon a system of ordinates, the form of 
the curve is of interest to us. We have to consider the 
spatially extended consciousness of the body to be the axis 
of the absciss. Over this the curve as an even elevation, 
must embrace its whole extent, for the consciousness of our C. Wernicke. 
70 
body continually accompanies us while awake, if only in a 
moderate degree of excitement. If we conform to the use 
of language, in which by consciousness is understood not 
its content, but its action also, or the process of excite- 
ment reflected in it, so we must differentiate the degree of 
consciousness in this respect. The degree of consciousness 
in the curve is expressed by the height of the ordinate, 
while its extent corresponds to the length of the absciss. 
If it is a consciousness of low degree, such as we con- 
stantly have of our body, and which can never be lost 
while awake, it follows that the stimuli of the world con- 
tinually act on the body, and the concept of the body has 
to be regarded as such a fixed unit, that it is always ex- 
cited as a whole. By this equable elevation quite a marked 
wave crest is somewhere produced, indicating the instant of 
the greatest state of excitement. It is a condition of the 
human brain that only one such wave crest can occur at a 
certain time. The wave crest indicates the highest degree 
of consciousness, the greatest intensity of the process of ex- 
citement and is empirically always present only once in a 
unit of time. It was then very pertinent, when we repre- 
sented the wave of excitement as changing in the psy- 
chophysical movement, and it is the wave crest, the 
second elevation, which essentially changes its place, while 
the first stage of the elevation continues its whole extent. 
The fact that only one wave crest is ever present in any 
curve, has given rise to the term unit ox nanoivness of con- 
sciousness. It is impossible to think, to do or perceive two 
things at the same time. The astronomer, in measuring 
time by the pendulum beat as the star passes the wires of 
the transit, either sees the star and then hears the pendu- 
lum beat, or hears the pendulum and then sees the star, 
and between both factors an appreciable time elapses, 
which varies in different observers, yet occurs in everyone 
and is taken into account as the astronomical or personal 
equation in comparing the results of different observers. 
In this example the wave crest must be considered as 
changing from the central projection field of optic perception 71 
Outline of Psychiatry in Clinical Lectures. 
to the acustic. The fact of the unit or narrowness of con- 
sciousness leads to the supposition that the spatial content 
of the curve, if it can be computed, always remains the 
same, in other words, that only a definite supply of living 
force is ever present in the brain for the course of the psy- 
chophysical movement. Fechner has illustrated this prop- 
osition by the following example: The miller, who is ac- 
customed to sleep amid the clatter of the mill, awakes as 
soon as the mill stops. It must be accepted that the acus- 
tic perception of the mill’s noise has maintained a psy- 
chophysical movement in the acustic projection field of the 
sleeper, which now suddenly disappears; thus the psycho- 
physical movement undergoes such an increase in some 
other part of the brain, that the degree of consciousness of 
the awake state is attained. Quite a large number of sim- 
ilar examples may be cited. The further conclusion may be 
drawn from them, that the spatial content of the curve 
remains the same while asleep, but the form of the curve 
differs from that while awake by the above described char- 
acteristic wave crest being more pronounced. Still Fechner 
had advanced the supposition, that being asleep and awake 
differ in that the place of the psychophysical movement 
would be different, what is correct in so far as the form of 
the curve will be admitted to influence it. 
If the wave crest is termed the place of the most in- 
tense action of thought, the nearest associated ideas must 
be regarded as contained in the ascending and descending 
limbs of the curve, hence the continuity of thought between 
the initial and terminal ideas. 
We have various terms for the- change of the wave 
crest, we speak of attention, when it is a matter of per- 
ception or thought, of will when acts or a process 
of association, which precedes them, is in question. 
Take a definite instance, like the contemplation of a 
work of art. The attention is then engaged for a long 
time with an optical perception, therefore the wave crest 
must be in the central projection field of the optic nerve. 
Under the influence of this wave crest all associated ideas C. Wernicke. 
72 
are called into consciousness one after another, this is the 
purpose of contemplation. The attention directed to an ob- 
ject then corresponds to a thought, in which, wholly with- 
out our assistance, a large number of preformed processes 
of association is raised above the “threshold of conscious- 
ness.” As this fact is a common experience, we believe 
we are able to voluntarily direct our attention, a delusion, 
analogous to that of self-consciousness. The more closely a 
person’s attention is directed to the work of art, the more 
the consciousness of the world and the body, as well as 
that of the personality recedes. Absorbed in contemplation one 
may forget where and who he is, but the consciousness of 
the body is shown to be retained, by the fact that he in- 
voluntarily changes his position, turns aside, makes move- 
ments of defense, etc., according to circumstances. The 
dominating wave crest in a certain measure takes a piece 
out of the consciousness of the body, in which optical or- 
ganic feelings of special intensity must exist, in any fur- 
ther relation the process is incapable of localization. While 
the attention was occupied with a definite part of the world, 
it is immediately diverted and turned to the body, if a pain 
or an unpleasant sensation affects some part of the anat- 
omy. If very intense, like a violent toothache, our impo- 
tency is at once shown by the attention being diverted by 
our senses. If the work of art, which causes the sense 
perception, is still present, the processes of association are 
stored up, as shortly before, but they are now inert, for the 
wave crest relates to the consciousness of the body and to 
a definite area. A very intense pain renders thought im- 
possible, what the disciples of Zeno have always opposed. 
The pain may be borne, but certainly the attention cannot 
be voluntarily directed to any object. Irrespective of the 
intensity of the stimulus, which has affected some organ, 
it here depends upon the associations, which more or less 
accidentally confer great significance to the momentary dis- 
comfort: the least hoarseness catches the singer’s attention, 
the slightest injury to the foot occupies the tourist’s com- 
pletely. The so-called limnal value of sensations depends 73 
Outline of Psychiatry in Clinical Lectures. 
in all senses on the presence of general attention. The 
fact, that it has a definite quantity varying but little in all 
persons, leads us to conclude, that the attention or, in 
other words, the height of the ordinate of the wave crest is 
nearly the same in all normal persons. The limnal value 
may be extensive, as in measuring the visual field, and 
certain concentric contractions in the clinical picture of an- 
aesthesia retinae, simply indicate a lowering of attention. 
In the neuroses after head injuries, railroad accidents, etc., 
this lowering of attention plays a great role, and no less in 
the insane. 
Gentlemen, you perceive from these remarks, that we 
possess a means of measuring attention by determining the 
limnal value of sensations, i. e., the height of the ordinate 
in the process of excitement attainable by the organ of con- 
sciousness subjected to investigation. In the examination of 
nervous patients this factor is to be taken into account and 
the procedure so conducted, that the patients are incited to 
direct their attention at the moment of the examination to 
the place and kind of examination. You remember I pre- 
sented to you a patient, in whom it was within my power 
to demonstrate either a total cutaneous anaesthesia or 
normal tactile sensibility, according to the method of exam- 
ination. We then hold, that a lowering of this limnal value 
under certain conditions indicates a lowering of the degree 
of consciousness. 
The capacity for normal attention is essential for the ac- 
quirement of new memorial images and ideas. In the fu- 
ture we will call this attribute of consciousness the ability 
to attend and understand by it something which is com- 
prehended by memory in the ordinary use of the term. To 
avoid future misconceptions in this matter, I propose here- 
after to speak of memory only in the sense that it refers 
to the old acquired possession of ideas, while by the ability 
to attend we un'derstand the ability “ to impress something 
on the memory.” We may test this ability by giving the 
patient a problem, a number of several units, a foreign 
sounding word, etc., to remember. If lost or lowered, it C. Wernicke. 
74 
may be due under certain conditions to a lowering of the 
attention. But you will later become acquainted with cases 
of disease, in which the attention is weli retained, but the 
ability to attend is very markedly lessened. We therefore 
perceive in the ability to attend a means of testing the 
action of the organ of consciousness, which depends on an 
independent and conditional attribute of the nervous ele- 
ments dependent on attention. 
A similar relation, as between attention and the ability 
to attend, we also find between the ability to attend and 
that of recollection. The above mentioned test of the abil- 
ity to attend reveals to us that under certain conditions 
memory defects are observed. In the above mentioned test 
they merely consist in forgetting a definite task given the 
patient. But from my last lecture you will have gathered, 
that these memory defects often embrace a very long per- 
iod of time, so that all impressions, events, opinions and 
knowledge gained within it, seem to be effaced from the 
memory. We very often meet with the same phenomenon 
in the insane, or after the course of the mental disease for its 
whole period or certain portions of it. If the ability of these 
patients to attend has been tested, and it has been found that 
it was lost or diminished, hence the memory defect appears 
to be the readily comprehensible result of lowered ability to 
attend at the time memories should have been acquired. 
Still the conclusion, that a memory defect is always due to 
a loss of the ability to attend in a given period is not justi- 
fied. Doubtless there are memory defects of other origin. 1 
refer to the remarkable cases of so-called amnesia re- 
troactiva, where a cranial trauma, an epileptic or apoplectic 
attack had completely extinguished the memory, not only 
of the time following, but also of the events shortly prior 
to the accident, then the recollection at the time of com- 
plete mental clearness and health. The above cited cases 
of general weakness of memory may also indicate such a 
retroactive effect of the disease, which conditions their origin. 
But subsequently their ability to attend is seen to be very 
materially lowered permanently. 75 
Outline of Psychiatry in Clinical Lectures. 
The gradual gradations from consciousness to uncon- 
sciousness are generally distinguished as states of the sen- 
sorium by the subdivisions of stupor, somnolency and 
coma. Still it is not ordinary usage to speak of stupor in 
such slightly lowered action of the consciousness, that a 
special examination is necessary to prove it. In the insane 
we will only exceptionally meet with noticeable stupor, while 
lowered attention and ability to attend are common. 
Gentlemen! We now come to a series of phenomena, 
which 1 have heretofore avoided intentionally, but which 
very often exercise on the process of thinking a very 
definite, as well as disturbing and inhibitory influence. 
These are the affective conditions or affects. We are as 
little able to define affective conditions, as we are pain; 
both are facts of inward experience, whose identity we 
presume in all persons, because their expressions and con- 
duct permit this conclusion. We know that pain has its 
counterpart, the feeling of pleasure. We also know that 
pain occurs under certain conditions, which may be stated 
in a general way, that those excitations produce pain, 
which are too intense for the useful function of the nerves, 
the conduction of sense impressions, and injure the nerves. 
We further know that pain occurs when the isolated con- 
duction is broken and the gray matter of the spinal cord 
encroached upon. Pain is an affection of this gray matter 
and seems not to occur without it. All this does not give 
a definition of pain, but shows that it has a definite pur- 
pose, an attribute, which must be ascribed to the simplest 
nervous system and not to vertebrates alone, and furnishes 
creatures with a sort of alarm signal for the avoidance of 
such agencies as might injure the structure of the nervous 
system. Its opposite, namely a nerve excitation conducive 
to the individual’s welfare, *seems to induce the simple 
feelings of pleasure, like that of sensual gratification, sen- 
sual pleasure, etc. The same relation the feelings of pleas- 
ure and pain have to the spinal organization, the affects 
seem to possess for the organ of consciousness, yet we can- 
not here state with certainty that the gray matter is the C. Wernicke. 
76 
sole bearer of this phenomenon. All that is compatible to 
the consciousness of the personality, to the me, produces a 
pleasant, what is incompatible, an unpleasant affective state. 
According to the degree of this affective state, we speak of 
affect or mood. Here it is also a matter of arrangement 
for defense, which may be acquired by the brain in the course 
of its development. Normally all complex processes of as- 
sociation, thinking, as we call it, are accompanied by a 
moderate affect, a sort of pleasant self-feeling (see above), 
which Griesinger has aptly termed the psychical tone. This 
calm, slightly exalted mood of the person in health does 
not impair the act of thinking, as well as other affects 
when only of moderate intensity. This even, quiet course 
of thought we distinguish as the state of self-possession. 
In all intense, stormy affects, be they of extreme joy or 
sorrow, anger and rage, the self-possession is lost and the 
ideas no longer occur in their inherent, preformed order, 
but are under the biased control of certain dominating 
thoughts, which perhaps may be equalized by counter ideas. 
A sort of inhibition of thought thus occurs, for the counter 
ideas arise by intimation and again disappear, so that a 
train of thought cannot be followed; we name this state 
distraction. 
Gentlemen, permit me to speak of the fact 1 have re- 
cently mentioned, that every thought is normally combined 
with a slight affect. After the somewhat teleological defin- 
ition of affects 1 have given you, you will not be surprised 
that the content of the ideas in thinking influences the at- 
tending affect. If we assume that a train of thought, 
which with respect to its contents is advantageous to the 
individual, has often been repeated, a condition, which is 
intentional brought about, e. g., for the purpose of educa- 
tion and the formation of character, we will encounter in 
the mental possession of this individual a group of ideas, 
which is united with an intensely pleasant affect. Other groups 
of ideas of the same individual of such kind are acquired, 
that an intensely unpleasant affect is permanently attached 
to them. Apart from the excitability of certain groups of 77 
Outline of Psychiatry in Clinical Lectures. 
ideas, the readiness of their reproduction or facility of re- 
call will depend on, whether they have been used frequent- 
ly or rarely. Both conditions are especially clear, when it 
is a matter of a train of thought, which may be the mo- 
tives of a person’s acts. In this sense we understand by 
normal quantivalence of ideas a very definite gradation of the 
relations of excitability, which vary in different individuals 
within a certain limit, yet in each individual conditions in 
a certain measure a preformed possession from differences 
of quality among the ideas. The content of the conscious- 
ness of the personality thus acquires its diversity and its 
individual color. The variation in character is essentially 
conditioned by the different quantivalence of those ideas, on 
which depend its actions under specified relations. In the 
norm we must take account of the fact that such super- 
quantivalent ideas are difficultly accessible of correction by 
counter ideas and accordingly become the unconditional pre- 
sumption for the action. The concepts of honor, modesty, 
chastity, etc., are such motives for the action of moral in- 
dividuals. We desire of the action of the consciousness, 
that the normal quantivalence of the ideas appear. In the 
insane we will often meet with deviations from this normal 
quantivalence of ideas. 
PART II. 
PARANOIAC STATES. 
IX. 
SYNOPSIS OF THE CLINICAL PROBLEMS. MENTAL DE- 
RANGEMENT. MENTAL DISEASE. PARANOIC STATES. 
THE UNCURED INSANE. PRESENTATION OF CASES. 
Ere we undertake the clinical examination of the insane, 
we will glance cursorily at the problems confronting us. In 
general terms we call the subject of our study mental de- 
rangement, an expression that is current among the laity 
and well adapted to designate all mental states deviating 
from the standard. Of these we will purposely choose for 
study the simplest, /. e., those we may hope to understand C. Wernicke. 
78 
without the possession of special preliminary knowledge 
other than the general views, which have been the subject 
of our previous discourses. The simplest states of the kind 
are the changes in the contents of consciousness existing 
after a mental disease, which fall into large groups, ac- 
cordingly as they are qualitative: falsifications of conscious- 
ness, or quantitative: defective states of consciousness. We 
meet with far more complex pathological phenomena in the 
real mental diseases, and the more acute and intense their 
course. The contrast lies between latent states and ter- 
minal disease processes, and it is quite natural that the first 
offer fewer difficulties for the comprehension. If we call to 
mind the previously established contrast between the con- 
tents and the action of consciousness, we have here ex- 
actly the same relations. We then find relative by the sim- 
plest conditions, when we take up the changes in the con- 
tents of consciousness in normal or approximately normal 
action of consciousness. Whereas during the course of men- 
tal disease we witness the abnormal action of conscious- 
ness. As the action of consciousness is a function of time, 
its product definite contents of consciousness, we may there- 
fore define acute mental diseases to be the change in the 
contents of consciousness, which we see consummated within 
a definite period. According to the stipulations of normal 
mental life such changes are combined with various emotions 
and affective conditions. Acute mental diseases are therefore 
almost universally accompanied by active emotions, and by 
the way, it is these, which render difficult the comprehen- 
sion and treatment of the acute mental diseases. The 
shorter the duration of the acute mental disease, the more 
intense will be generally the attending affect, and so, in 
case it does not terminate in recovery, the greater will be 
the resulting change in the contents of consciousness, 
whether qualitative or quantitative. 
If we still have to suppose that equally normal intel- 
lectual action may occur when the consciousness varies 
greatly as to the richness of its contents, you will not then 79 
Outline of Psychiatry in Clinical Lectures. 
question, that among the persons previously mentioned (1) 
using only a small number of concepts, proportionately just 
as many intelligent individuals will be met with as among 
the representatives' of quite entensive knowledge. 
Gentlemen! Our next task will then be to become 
acquainted with cases of mental derangement, which after 
the mental disease present their residues in form of changed 
or defective contents of consciousness. The action of con- 
sciousness is again normal, the grave affects, which accom- 
panied this change, have disappeared. The patients there- 
fore are not entirely free from affects, but in general free 
from morbid affects, so that the latter, even when they are 
connected with the changed contents of consciousness, are 
not special symptoms, but comprehensible by the same 
standard as in the sane. We now find a very similar con- 
dition in many chronic mental diseases. These present us 
the picture of a slow and gradually effected change in the 
contents of consciousness, a process then that also happens 
to the normal organ of consciousness, but is here due to 
internal morbid changes in the organ. The contents of con- 
sciousness of sane individuals actually undergoes a con- 
stant increase even to very old age. This applies especially 
to the consciousness of the personality, for it implies the 
sum of the original data. When the parity is effected by 
slow disease processes, we observed a very gradual change 
in the personality, without the normal preliminary conditions 
of the change being given in external relations. The in- 
tense affects, which are not spared the sane, will often start 
from the morbidly changed contents of the personality, 
without it being morbid of itself. If we try to complete the 
analogy with brain diseases, the gradual change in the con- 
tents of consciousness is to be compared to the gradual 
aggregate of focal symptoms in the instance of a tumor of 
slow growth and replacing the brain matter (not merely 
pressing upon it). As in such cases, the symptoms of the 
mental disease of an extremely chronic course bear the stamp 
of incurability from the first, which in this instance is due to 
(1) Alienist and Neurologist, Vol. XX, p. 166. C. Wernicke. 
80 
the complete fusion with the normal contents of conscious- 
ness, in the former to the purely local effect of the de- 
struction. It is almost superfluous to say, that just as the 
changes in the contents after acute mental diseases—with 
exceptions still to be mentioned—represent incurable states, 
our clinical material will chiefly consist of incurable, so- 
called “old cases,” and also of certain, still progressive, 
cases very closely related, but fixed in their external manner 
and manifestations of the action of consciousness. 
The majority of inmates of many years standing in large 
insane asylums consists of such patients, without the proper 
value usually being placed on their differentiation into two 
categories, afforded by their mode of origin. If from this 
material we eliminate the defective states, we may embrace 
the still very large number of cases remaining under the 
name of paranoic states, because they present the common 
sign of a pathological change in the contents of conscious- 
ness, in other words, a falsification of consciousness. The 
falsification of the contents of consciousness is either 
residuary, when the result of a mental disease, or the 
expression of a chronic progressive mental disorder. 
For a further classification of the residuary falsification 
of consciousness, their extent will naturally be decisive. We 
have seen, that we may speak of three different parts of 
consciousness: the personality, the world and the body; 
for brief designation of symptoms occurring in each of these 
I propose the terms autopsychical, allopsychical and soma- 
topsychical. It is a matter of residuary autopsychical 
falsification of consciousness, e. g., in all of those numerous 
cases, which may be discharged improved after the mental 
disease and cannot be called recovered, for they do not have 
a perfect appreciation of the disease (see Alienist and 
Neurologist, Vol. XX, p. 378). The false ideas, chiefly 
false judgments, of these individuals usually refer to their 
treatment and the necessity of detention in the asylum, to 
which they owe their relative recovery, and as they are 
strengthened in their opinion by similar false judgments of 
other patients at the time of their asylum residence and 81 
Outline of Psychiatry in Clinical Lectures. 
believe to have witnesses in them, so is it explainable, that, 
according to the temperament and character, they complain 
more or less energetically and bitterly of the institution and 
discredit it. I recall to your minds the professor and Doctor 
of Philosophy discharged and improved, who had again 
taken up teaching, and the wine merchant treated here 
years ago and who"now has a fine business, both of whom 
have gone to the highest officials with their complaints of the 
injustice suffered at the hands of the Clinic. A part of the 
attacks directed of late by the press against our manage- 
ment of the insane may be traced to such sources. 
As you see, this point is of great practical importance. 
Not only the alienist, but also the medical profession and 
the public dependent on its aid, has an interest, that the 
explanation be carried to the farthest limits. 1 therefore go 
somewhat more fully into it by starting from my remarks 
on the consciousness of the personality in my seventh 
lecture (1). A lack of appreciation of the disease practi- 
cally amounts to the same as the increase in the aggregate 
of memories of a person about a certain number of data not 
corresponding to the reality, such as may be gotten from a 
dream. If we add these, often very fantastic, as actual 
members to our store of memories, what incalculable con- 
sequences would arise for our actions, our opinions of men! 
But it is exactly the same with the falsely judged data of 
the insane and retained as such in*their memory. I must 
now remark that the lack of appreciation of the disease 
may vary in degree. In acute mental diseases it is quite 
common, that the acme of illness occurs in the beginning 
and the patients then have an appreciation of the more 
severe symptoms of this acute stage, but not of the time 
following. It is natural that a certain credence is placed in 
the statements of such apparently rational patients who 
regard their admission justified, but not their retention in 
the asylum. If the acute stage, from which the apprecia- 
tion of the disease is gained, occurs at a later period, the 
(1) See Alienist and Neurologist, Vol. XX, p, 378, C. Wernicke. 
conclusion seems authorized to the patient, as to all the 
laity, that the commitment to the asylum and the im- 
pressions there gotten, might have caused the disease. 
Further the lack of appreciation of the disease is not always 
an incurable condition, but it quite often occurs that the 
memory of the supposed facts of the illness and the affects 
combined with it gradually fade in the course of time, es- 
pecially when the normal stimulus of regulated action is not 
wanting. The same patients, who have once bitterly com- 
plained, now generally refer reluctantly to their institutional 
life, say that it is half or wholly forgotten and their 
aversion for the physicians and personnel has no practical 
consequences. You will remember that we have repeatedly 
made use of this consideration, when we have favored a 
return to civil life and the taking up of an occupation 
adapted to the ability of these patients, who have not a full 
appreciation of their disease, in spite of our long expectation. 
Unfortunately a second large category of patients is 
not destined to return to civil life, although their mental 
disease has terminated and not unfavorably. But they are 
distinguished from the first category by the fact, that they 
present, beside the complete lack of appreciation of the 
disease, fixed delusional ideas, which belong to the great 
group of explanatory delusions to be studied later. I 
have already intimated, that it is to be considered merely 
the logical sequence of the lack of appreciation of the 
disease, if these patients regard their asylum residence as 
a wrong done them. A step further leads to the very 
natural idea of persecution, that the purpose of the asylum 
residence is hostile, either to take the patient from his 
business, to injure him civilly, to put him away temporarily 
or forever, or even to make him crazy by the enforced associa- 
tion with the insane. There are then usually certain persons, 
if often merely executers of a higher power, who are 
regarded as’persecutors and enemies. The further consoli- 
dation of this delusion system varies greatly according to the 
consciousness of the personality (individuality), as well as 
the energy of the action by reason of the motive so gained. Outline of Psychiatry in Clinical Lectures. 
If the source of persecution is sought in large corporate 
bodies, like the church, Free Masons, or state officials, the 
executive organs, acting under compulsion, are occasion- 
ally blamed, but first the conjecture and later the certainty, 
which is the source of the persecution is directed against 
single persons, according to the individual data, as e. g., in 
the common case of the husband suspecting his wife, the 
real purpose of the asylum residence being to make an 
adulterous relation possible. In such cases the physician is 
almost always charged with being an accomplice, and he is 
the next tangible accessory to the intrigue. In many cases 
an explanatory delusion of persecution later occasions the 
further explanatory delusion of consecutive grandeur, when 
the requisite co-operation of the officials very correctly leads 
to the opinion, that such an improper procedure can only have 
reference to an important person and the power of the state 
made to serve the purpose of the persecutor. All these pa- 
tients cannot be discharged, for they do not conceal their 
proneness to violent and generally dangerous actions. The 
one root of their delusional system, the detention, is 
therefore not to be removed, and hence the delusional sys- 
tem is constantly supported and strengthened. But within 
the asylum in the course of time the affect may be lessened, 
especially by becoming habituated to useful employment, 
and a passibly contented existence led. 
As representatives of the third category of old asylum 
inmates, I first present to you the patient Bother, 61 years 
old, whom 1 have known for 14 years, that is since 1871, 
as a terminal case of acute mental disease, of which un- 
fortunately we have no farther data. Since then he has 
led an active life within the asylum, been quiet and well 
behaved, with the exception of brief periods of excitement 
at intervals of years and generally due to some interference 
with his work, and presents a normal physical condition. 
He goes in and out at will and has a key to the garden 
and his ward. As you see, his conduct exactly corresponds 
to the situation. He is polite and obliging, without being 
obsequious, evidently confides in the asylum physicians, is C. Wernicke. 
satisfied with his home in the asylum and his work, and if 
lie wishes to be discharged, he can be readily quieted 
by the assurance that here he is free from care. 
He seems perfectly able to take the steps necessary to 
secure a position after discharge. His answers are prompt 
and in accord with his degree of education. His circle of 
interests seems no narrower that may be expected after 24 
years of life apart from society. He keeps informed from 
the papers as to the most important political data and news 
of the day. Attention and ability to attend may be shown 
to be normal. So it seems as though we have a sane per- 
son, one of those unfortunate victims of asylum physicians’ 
neglect and unscrupulousness, who are so often wrongfully 
held, if you will credit the statements appearing daily in 
the newspapers from well meaning, but uninformed and 
therefore at least imprudent philanthropists. I do not doubt, 
that a commission of laymen permitted to discharge pa- 
tients in accord with their own opinion—the general re- 
formatory idea of these philanthropists—would pronounce 
the patient sane, and the more so, for he is circumspect 
and reticent before strangers. But he gives us his whole 
confidence and frankly relates his experiences, after once 
gotten to talk. First of all it is remarkable that he knows 
nothing'of the mental disease he had, he came to the hos- 
pital with an acute febrile trouble and regards it really 
wrong or an error, that he has been kept so long, if he 
also admits the physicians may always' have meant well 
by him. He tells of a fight with one of his garden hands 
shortly before coming to the asylum. He had been thrown 
down stairs by this person and had his neck broken. 
(Who?) (1). “ Why I.” (But are you not alive and sit 
here?) “ Well, yes, but the other probably lies there 
still.” (What other?) “ Why, Bother.” (Is it possible 
that you have been dead?) “ Of course, everyone has a 
double.” 
The patient also relates that he has witnessed things, 
(1) The parentheses here imply questions. Trans. 85 
Outline of Psychiatry in Clinical Lectures. 
which would not be believed: he has one been a steer and 
and as such been inhumanly tortured and then slaughtered. 
He describes how a ring was put through his nose and he 
dragged away. He has also been crucified once and with 
two thieves. (Like Jesus Christ?) “Yes, just so,” (Are 
you Jesus Christ?) “Yes, 1 am Jesus Christ.” 
He further states, that he has also been Gottfried von 
Boullon, and describes the armor he has worn, and he has 
been a blue bottle as well (he means a tly) and as such 
flew about. 
If we here meet with the strangest ideas in the con- 
sciousness of the body and the personality, the patient no less 
has the most perverse ideas of the world. From the beau- 
tiful garden, where he has last worked, a pair of stairs 
lead down to extensive subterranean caverns. Various 
fabulous monsters are there: large snakes, beasts of prey. 
This cavern extends under all of Breslau and how much 
farther is unknown. The sun lights it and the earth is seen 
to revolve about it, like a large ball. (Does it not fall, or 
is it supported?) “ It rests on a large pointed stone.” 
He has traveled extensively. In three days he walked 
from Europe to America over a causeway about as wide as 
an ordinary road. From time to time he found a tavern 
where he could spend the night. On each side he saw 
the blue sea and the most beautiful ships. He once went 
around the Black Sea in a few hours. They were engaged 
in draining it. 
Regardless as to how the patient has arrived at these 
numerous false ideas, you will admit that it is a matter of 
a falsification of the contents of consciousness in the ex- 
treme. All three parts are equally affected, but in such a 
way that the most contradictory ideas exist simultaneously 
and do not interfere with each other, that the most impos- 
sible is not sensed as contradicted by actual daily experien- 
ces. In a certain measure it is a consciousness fallen to 
pieces, so, as you see a state of “disintegration of the in- 
dividuality ” completely excludes any systematization. 
Therefore we cannot speak of a real delusional formation, C. Wernicke. 
86 
and the absence of any delusion of persecution or grandeur 
occurring from logical thought will seem perfectly natural to 
you. The surprising lack of judgment displayed by the pa- 
tient in regard to the morbid contents of his consciousness 
rarely occurs in ordinary life. Still he appears perfectly 
competent in his work. He judges his fellow patients in 
great part falsely, for he recognizes only the disturbed and 
excited to be insane. That such a person cannot live in 
society, cannot care for himself and be self-supporting, 
needs no proof, he is forever assigned to institutional care. 
This patient is in a measure merely the paradigm of 
all cases of extensive residuary falsification of consciousness. 
The extent of the derangement prevents the construction 
of a delusional system. But the relatively complete recov- 
ery from the disease process renders possible an approxi- 
mately normal intellectual action within the circles of inter- 
est of his occupation and so an active life. 
X. 
PRESENTATION OF CASES (Continued). 
Tlie patient, 1 present you to-day, is a typical example 
of chronic allopsychical falsification of consciousness. Mrs. 
Reisewitz, 45 years old, is the widow of an agent, whose 
disease has gradually developed for five years from just 
appreciable beginnings and will probably progress still far- 
ther. On entrance she attracts your attention by her 
formal and rather dignified manner, and her facial expression 
is one of solemnity. On being questioned she stated she 
has been in Dalldorf, was brought here from there and 
those about her there must have come to Breslau. She 
does not recognize this to be a hospital, it is a “holy 
place,” “God’s house,” everything has a churchly solemni- 
ty. The purpose of her stay here is the preparation for an 
important position later, for now she is very unworthy, and 
it is a great] honor for her to be received here. Perhaps 
she owes it to a higher priesthood, to whom she has ap- 
pealed in her troubles. It is generally known that she has 
had much trouble and misfortune, her name is familiar to. 87 
Outline of Psychiatry in Clinical Lectures. 
everyone in Breslau. Except this remark indicative of ex- 
alted self-confidence, she preserves a submissive nature, 
rises and bows whenever spoken to and does this to all 
her fellow patients, even the totally demented paretics. 
She often apologizes for having behaved improperly and 
implores that her words be not too strictly weighed. She 
considers all her fellow patients men in disguise, mostly 
priests of high position, who are here partly for penance. 
The physician ralso belongs to the priesthood, if he may 
have been a physician formerly. She calls a 13 year 
old girl the Duke of Arco, the head nurse Emperor 
Frederick, the other nurses certain princes. All these per- 
sons have been with her in Dalldorf, if they are now 
changed in appearance. She alone has not changed. 
You see, that the facts, we have gotten, permit us to 
conclude the existence of a so-called systematized delusion, 
which is essentially of a religious nature, and has developed 
an autopsychical falsification of consciousness, for the patient, 
after undergoing a period of temptation, will have to play 
the role of a saint or prophetess. But especially striking 
seems the interpretation of the persons and general sur- 
roundings in a sense corresponding to this religious delusion. 
With her apparent self-possession, quiet behavior, perfectly 
normal general feeling, we will not be able to assume, 
that her senses delude her and therefore incapable of cor- 
rectly observing the things and events of the world; never- 
theless she explains everything in the sense of certain 
prevailing ideas and so often of a religious nature. She 
then affords us an excellent example of disordered secondorv 
identification, owing to the contents of consciousness being 
changed by a chronic mental desease. I will refer later to 
the anamnesis, so characteristic of cases of this kind. With 
respect to the present state it is to be remarked, that the 
patient is not entirely free from hallucinations. Those of 
hearing appear now and then, while those of smell and sub- 
jective cutaneous sensations are quite frequent. The first 
are interpreted as blessings, perhaps the voice of God, 
those of the other senses, “the inhalation” of chloroform C. Wernicke. 
and the ‘‘electrical treatment” leave a debilitated feeling 
and are usually patiently submitted to as tests, but yet oc- 
casionally cause fits of anger with violent cursing. A 
longer examination would be tiresome, nevertheless correct 
data are obtained as to the personal facts of the patient 
until the beginning of her illness, hence memory defects do 
not exist, attention and ability to attend are approximately 
normal. 
Another patient, in whom the consciousness of the 
world has been perfectly retained through the whole course 
of the disease to the present moment, while the conscious- 
ness of the body, but especially of the personality, shows 
marked changes, you will perceive to be the opposite of 
the former case with such pronounced allopsychical falsifi- 
cation of consciousness. We may consider it an example 
of a residuary somatopsychical falsification of consciousness. 
Tscheike, a cook, 45 years old, was treated for four months 
at the Clinic five years ago, and transferred from here to 
the Berlin insane asylum. Discharged from there relatively 
improved, she has, after many futile efforts to resume her 
trade, finally come back to our Clinic. The period of her 
first stay may be regarded as the acute stage of mental 
disturbance, which had developed very gradually for two 
years and was accompanied by various severe derangements 
of the the general condition. She is now entirely free from 
such troubles, looks well, bodily functions are regular, her 
weight is maintained and her conduct to-day shows nothing 
out of the ordinary. Her answers are prompt and rational. 
She is perfectly oriented as to her surroundings, her pres- 
ent position and her former illness, as well as to all her 
personal relations, and has a specially good memory for 
certain details of her illness. Her attainments are in ac- 
cord with her station in life and degree of education, her 
disposition, in spite of a certain feeling of illness, is more 
exalted than depressed. On the ward she does not always 
behave properly, is only occasionally to be induced to go 
to the sewing room, and usually perfers to meddle in vari- 
ous affairs that do not concern her, to give advice, annoy Outline of Psychiatry in Clinical Lectures. 
her feliow patients by jests and childish pranks. For in- 
stance she jerks off the bed covers, unexpectedly pours 
water in their faces or steals food from them or the kitchen. 
The physician’s visits are generally disturbed by her inter- 
ruptions. She disobeys the medical orders and when put 
to bed for discipline, she does not hesitate to come on the 
hall undressed. You see, that the patient’s conduct is 
far from normal, but requires so much consideration, 
and patience from those about, that she can only live under 
the special conditions of an asylum. You will see subse- 
quently that many patients are in the same position, and 
essentially in consequence of a certain quarrelsomeness are 
incapable of living otherwise than in systematic asylum 
relations, owing to an assuming, largely egotistical conduct 
requiring constant attention after the mental disease. But 
on closer inspection our patient is found to entertain a 
large number of false ideas. At the time of her illness she 
had 'a bronchial catarrh. She was then so filled with mucus, 
that it has produced in her body a primitive man, lamprey 
or an amphioxus—she uses these three term synonymously. 
The primitive man has troubled her greatly, has inhabited 
her body like a living child. It had primarily originated in 
the diaphragm, has a transparent, pinkisk body, of mucus— 
as she might have seen it in the aquarium—has a cherub’s 
head and a pointed tail. It is so situated within her, that 
its head is in her brain, the body along her spinal column, 
the tail over her anus. It has ofter tried to force its way out, 
as she has noticed from the pricking in the top of her head 
and at her anus. It lives on what she eats, but principally 
on what she drinks,hence she must drink so much. Since 
then everything has been double in her, double nerves, 
double pulse, double brain. From that time she has also 
had a very young face, like that of a^fifteen year old girl 
with a cherub’s head, and her pitted skin has become 
smooth. (Patient actually has numerous pock-marks on her 
face.) During her illness she once vomited the right half 
of her brain, intense headache and nausea having preceded, 
the vomit looked like yeast, so she felt that the right half C. Wernicke. 
90 
of her brain was damaged. Later the affected hemisphere 
lias been restored. From the illness she has also obtained 
a double mind, “in one part all that concerns her work, in 
the other politics and science.” In fact the patient seems 
to definitely differentiate her early mental possession, which 
comprise essentially her interests as a cook, from her 
thoughts since the beginning of her disease. She believes 
she has a “knack for everything” and has apparently read 
a number of books, in which she could take an interest, 
but did not understand. She speaks of Haeckel’s “Primitive 
Man or Amphioxus,” but believes that Haeckel implies that 
they are the same. According to her idea a person has 
twenty-seven senses: “thoughtfulness, combativeness, 
hygiene, language, literal sense, color sense, art sense,” 
the others do not occur to her. She writes essays on 
political topics, and 1 will read you the beginning of one: 
“the lowest class of persons is utilized to save life of the 
higher. Consequently poor individuals contract acute or the 
opposite. This stomach trouble is combined with chlorosis”, 
etc. She claims especially to know something of medicine, 
to be able to treat fractures, apply dressings, cure diphthe- 
ria, etc. Hence her annoying interference during the 
physician’s visits. As to the origin of these falsifications of 
consciousness, in part somatopsychical, in part autopsychical, 
we will study fully later. Here I will merely say, that in 
this patient we have observed the period of origin of the 
somatopsychical delusions and therefore can prove them due 
to abnormal bodily sensations. If such a fanciful idea could 
arise from her own body, we must realize the peculiar 
position in which such a patient is placed. These patients 
are wholly unable to express the morbid feelings, heretofore 
entirely unknown to them, completely devoid of analogy 
with the normal sensations of the body. According to the 
individuality similes,similarities, analogues are then obtruded 
on the consciousness to aid in their description. At the 
time of the acute affects only too often do such patients 
complain how indescribable, unspeakable, unparalleled in 
their kind are the feelings they suffer. The more or less 91 
Outline of Psychiatry in Clinical Lectures. 
distinct localization then affords the chief basis for the con- 
struction of an explanatory delusion, whose several com- 
ponents are taken from the individual’s physical knowledge. 
Our patient has apparently been crudely influenced by 
Haeckel’s writings, when formulating her delusional system. 
A further explanatory delusion is the basis of the autopsy- 
chical delusion, that by the disease she has come into 
possession of new intellectual power relating to politics and 
science. The self-perception of a changed trend of thought, 
due to a fundamental alteration of the contents of consci- 
ousness, expresses a point, which I will discuss more fully 
later. The absurdity, apparent mental enfeeblement in this 
intellectual process accompanied by exalted disposition is 
fully explained by the inconsistency with her previous 
course of education. 
An even better picture of residuary somatopsychical 
falsification of consciousness you will call to mind from the 
previous semester. 1 then presented to you a woman, 65 
years old, of whose past we could ascertain nothing definite. 
According to her statement she was seriously ill 18 years 
ago, when her whole body, but especially its external con- 
tour, had been deformed. She complains of her frightfully 
ugly face, her clumsy and awkward extremities, the al- 
tered complexion, her imbecilic expression, etc., while in 
reality she was a graceful old lady of good form and rela- 
tively intelligent appearance. Abnormal sensations did not 
exist, and there were no disorders of the general condition. 
Nevertheless on careful examination other marked changes, 
which might be called defects, could be proven, and such 
defects were especially prevalent in the allopsychical 
spheres. Besides with relatively good attention, the ability 
to attend was appreciably blunted, so that we concluded 
the residuary falsification of consciousness was complicated 
by senile mental derangement. The first seeming clearness 
of the case thus proves to be deceptive. 
Clearer by far is the clinical picture of a residuary 
somatopsychical falsification of consciousness in the other 
case presented at that time. It was, as you remember, C. Wernicke. 
92 
the case of a young man, Biega, 20 years old, who claims 
to have been deformed by his disease, so that he is hunch- 
backed, the upper ribs sunken, the lower ones awkwardly 
prominent, the shoulders appreciable lowered. Nothing 
was to be observed objectively of all these changes, they no 
longer caused the patient any trouble, blithe well remembered 
the time when this change had appeared with pain and 
indescribable sensations, a period, which lasted for years. Had 
it been possible to get the patient to talk, it could have been 
demonstrated that he had no defects, and by a special test 
it was possible to show that attention and ability to attend 
were normal. But yet at the first glance the patient’s 
whole bearing and external appearance gives the impres- 
sion of profound mental derangement, his bent posture, his 
reticent answers, his gloomy expression, cold extremities 
and cachetic complexion attract our attention. Besides we 
learn, that he is wholly inactive, avoids his fellow pa- 
tients, eats insufficiently and is very negligent of his per- 
sonal appearance. The suspicion, that the patient suffers 
from bodily sensations is confirmed by an examination, for 
it reveals that he thinks he feels an obstruction and oc- 
clusion of his intestinal canal near the anus, complains of 
the severest pains and various abnormal sensations in 
defecation and, if with the reservation of hopelessness, 
besought medical aid for his peculiar trouble. 
Mrs. Schmidt, 57 years old, the widow of a mason, 
whom 1 next present, appears perfectly well, physically, 
complains of no derangements of her general condition and 
very quietly and self-possessed tells of her troubles. The 
cause of her compulsory conviction was the annoyances to 
which she had been subjected at home, and to which she 
had replied by threatening her relatives and other inmates 
of the house, she had been squirted at and sprinkled, and 
been shot at from all sides. Yet we will let her tell her 
own story. “1 felt that it was squirted on my skin in a 
fine spray from a syringe, generally the skin of my face 
got it. It happened when 1 stood at the window, that 1 
heard a signal, and then 1 got a squirt, often in the eyes, 93 
Outline of Psychiatry in Clinical Lectures. 
so that 1 could not see. At first the bone was also injured, 
it became red and inflamed, and 1 also heard the shot fall, 
which have wounded me in the arm, breast and other parts 
of the body. Something has struck the skin of my feet, 
particularly the heels, so that I could not walk for eight 
days. Occasionally 1 get strong injections when 1 go to 
bed, which stupefy me. At any rate the walls were hol- 
low and passages have been made, from which 1 have been 
squirted. 1 do not know who persecutes me so, 1 consider 
it a chastisement, but do not know who has the right to 
punish me so.” 
She then tells, that the medical visits, which had pre- 
ceded her conviction, had not been properly made. A 
woman dressed in the clothes of Dr. H., whom she knows, 
had been sent to see her. But she had recognized by the 
beautiful teeth that it was not a man but a woman. Here 
in the asylum the persecutions have in great part ceased. 
Still we learn from the clinical history that she has com- 
plained of having been annoyed about her genitals during 
the night and of having seen a shadow. On the ward she 
has complained of other bodily abuses. At home her teeth 
had been forcibly broken off and her lips glued together and 
tightly closed by a viscid substance. Burning pains in the 
face, of which she often complains, she explains by the fact 
that some corrosive substance has been sprinkled over her. 
With regard to the development of the disease, we have 
learned from her son-in-law, that for five years she has 
believed herself persecuted in this way and for some years 
before had been solitary and mistrustful and no longer 
went out. She had periodically complained of voices, 
which came from the wall, without expressing herself more 
fully. Owing to distrust she finally discharged the servant 
girl and did the housework herself. She had not owned one 
of her grandchildren, but claimed it might have been sub- 
stituted. She had finally threatened to break all the win- 
dows in the house. 
The patient is evidently afflicted with a delusion of 
persecution of chronic development, and we have to regard C. Wernicke. 
94 
a number of morbid sensations and tactile hallucinations as 
its basis. This patient also notices changes in her body; 
but contrary to the previous patients, she ascribes these to 
external agencies and so, besides the somatopsychical, there 
is an autopsychical falsification of consciousness. We will 
find the same delusion of persecution in the following case, 
yet of entirely different origin. 
Mrs. Reising, 50 years old, the vigorous and apparently 
well nourished widow of a mason, complains that she has 
been enticed away from home and brought here by a police- 
man. This commitment to an insane asylum, counter to 
her wishes, is evidently an act of revenge on the part of 
Mrs. W., who is acquainted with the Police Commissioner 
of the district and is intimate with him. Thus it would have 
been possible for her to use the police for the furtherance 
of her plans. She has known this Mrs. W., a midwife, for 
six years. As she, the patient, is childless and having seen 
that Mrs. W. treated her daughter badly—“the urchin was 
in the mother’s way,” she interjected—she had taken the 
child to bring up. Two years later the child had been 
taken from her for no reason. In the meantime the patient 
had learned that Mrs. W. led an immoral life and is a 
vicious and quarrelsome person. She has noticed soon after 
the child was taken away, that she must have been 
slandered in certain saloons, among other things she has been 
charged with sexual intercourse with the husband of Mrs. 
W., she has been insulted and annoyed on every occasion, 
it has been said to her face on the street that she is a 
whore, etc. Only Mrs. W. could be to blame for it all, for 
she is capable of it. She has finally made a complaint of 
“vicious persecution for a year and intentional abduction of 
the child,” but does not know what has become of it. Fin- 
ally, to be let alone, she moved to the small city K., but 
has noticed that she is insulted by the people. Evidently 
W. has written and incited the people against her. She 
then came back to Breslau and found it worse than before. 
She has even heard the words whore, prostitute and the like 
from little school children, and doubtless the midwife, W., Outline of Psychiatry in Clinical Lectures. 
is to blame for it all. Three weeks before she went to the 
Recorder about her troubles with W., when, as she cor- 
rectly describes, an official physician visited her on the 
Recorder’s order. She, the patient, still construes the affair 
very differently; she believes that the Police Commissioner 
has illicit intercourse with this Mrs. W., who has induced him 
to send her, a perfectly sane person, to the insane asylum. 
You see, that the woman knows how to give her 
delusion System a certain appearance of probability. She 
speaks correctly and in accord with her degree of education 
and has an intelligent and forcible expression. She has been 
in the asylum three months. At first she was very urgent 
for a discharge, became readily excited on refusal and often 
said things, which indicated a continuance of hallucinations 
of hearing. She has gradually become more affable and 
friendly,and the hallucinations of hearing seem to have ceased. 
Besides she knows nothing of “voices”, for she has ap- 
parently projected her hallucinations to persons about. 
She explains her detention in the asylum by the fact 
that the physicians must act according to the instructions of 
the police. We have heard of no bodily complaints except 
an occasional gastralgia. She lost seven pounds in weight 
during the first two months, but has gained somewhat since 
then. 
Mrs. Reising is a typical example of a form of chronic 
progressive falsification of consciousness quite frequently met 
with. Hallucinations of hearing of annoying and threaten- 
purport seem to afford the chief foundation, so that we are 
justified for the present in maintaining a special form of 
allopsychical falsification of consciousness. We will later 
get a better comprehension of the case. 
( To be continued.) OUTLINE OF PSYCHIATRY IN CLINICAL 
LECTURES. 
PARANOIAC STATES. 
DR. C. WERNICKE, 
Professor in Breslau. THE 
Alienist and Neurologist. 
VOL. XXI. 
ST. LOUIS, JANUARY, 1900. 
No. 1. 
ORIGINAL CONTRIBUTIONS 
OUTLINE OF PSYCHIATRY IN CLINICAL 
LECTURES.* 
PARANOIAC STATES. 
By DR. C. WERNICKE, 
XI. 
INTIMATE RELATIONSHIP OF THE SO-CALLED “OLD” 
teraminal Cases and the chronic psychoses. 
EXPLANATORY DELUSIONS OF AUTO-PSYCHICAL, 
ALLO-PSYCHICAL AND SOMATO-PSYCHICAL ORIGIN. 
AUTOCHTHONIC IDEAS AND HALLUCINATIONS. 
Professor in Breslau. 
Ere we make the acquaintance of new patients, it is 
necessary to tarry somewhat with those already presented, 
while they are fresh in your memory. We will first con- 
sider the matter of nomenclature. According to the termi- 
nology now in vogue all these patients would be instances 
of chronic delusional insanity or paranoia. If we should 
thus imply that paranoia should be a well characterized 
clinical type of disease, it would pave the way to the 
greatest confusion of conceptions, for the cases differ so 
by Dr. W. Alfred McCorn, Resident Physician "River Crest,” Astoria. L 
I., New York City. 2 
C. Wernicke. 
much from each other. We obviate this incongruity when 
we speak of paranoiac states and include among them all 
those chronic mental derangements, in which a falsification 
of the contents of consciousness confronts us, while the 
action of consciousness is well maintained. Consequently 
we believe the view generally held by the older authors 
to be right, that by paranoia should be understood 
a predominant derangement of the intellect. It is very con- 
sistent with this extremely broad definition, that the cases 
possess such marked diversities, not only with respect to 
the present condition, but also in their genesis. As to the 
variation of the present disease types, we could readily 
characterize them more accurately by appropriate names, so 
we will employ the terms autopsychosis, allopsychosis and 
somatopsychosis and their combinations. For a falsification 
of the contents of consciousness embracing all three of its 
parts the name total psychosis would be suitable, then for 
one of these, in which one part is prominently affected, the 
respective name combined with the proper corollary. Accord- 
ing to this terminology the gardener Rother first pre- 
sented would be an example of total chronic psychosis, Mrs. 
Reisewitz would have to be designated as chronic auto-allo- 
psychosis, Tschieke as chronic auto-somatopsychosis, Mrs. 
Reising as chronic allopsychosis, Biega as pure chronic soma- 
topsychosis, Mrs. Schmidt as combined chronic allosomato- 
psychosis. By the corollary “residuary” that group of cases 
in which the disease process is to be regarded as termina- 
ted either recently or long ago, and to which belong the 
recoveries without appreciation of the disease, would be 
given their special significance. 
The necessity of this last distinction may however lead 
us afield in the choice of another somewhat simplified no- 
menclature. Perhaps it would be proper to reserve the name 
chronic mental derangement exclusively for the residuary 
cases and to employ that of psychosis with the proper 
qualifications to the mental derangement still active. If we 
favor this nomenclature, all the cases of relative recovery 
(without appreciation of the disease) and the two patients 
Rother and Tschieke belong in the group of chronic resid- Outline of Psychiatry in Clinical Lectures. 
3 
uary mental derangement, all the others presented or merely 
mentioned in that of the true chronic psychosis. All psy- 
choses, which have not recovered, but are stationary, come 
under the group of chronic mental derangement according 
to this conception. 
If such a distinction, for we might admit it as a 
clinical requirement, must be made, you will ask, if it 
would not be more proper to treat separately from now 
on the terminal cases and the chronic psychoses. But my 
introductory remarks will remind you that the sign of falsi- 
fication of consciousness occurs in both categories of mental 
derangement, and as you become acquainted with all the 
inmates of our Clinic, you will find a very large number of 
patients in which an immediate decision as to which of the 
two categories they belong, is impossible, for we have no 
account of their past. But when complete data are to be 
obtained, they often extend so far back that inaccuracies 
and falsifications seem unavoidable, and therefore, just as 
owing to the comprehensive faultiness of observations by 
laymen, the subsequent determination and decision between 
the two groups are not attainable. Hence it is a practical 
necessity to unite all these “old cases” in a single large 
group, that of the paranoiac states. 
But if we go more fully into the matter we understand 
the reason of this intimate connection unquestionably pres- 
ent. Permit me to allude briefly to the point of view deci- 
sive to my mind, as it is impossible to discuss it now as 
fully as it deserves from its theoretical interest. 
The contents of our consciousness have been repre- 
sented to you in the introductory lectures as something 
acquired, and surely acquired by the function of the organ 
of consciousness. Each new acquisition corresponds to a 
very definite arrangement of jointly functionating associative 
elements. The stability of these functional colligations we 
had found to vary, according to the frequency with which 
their function is exercised. But that this stability occurs in 
a proportionately high degree in the most complex associa- 
tive colligations, we might then conclude that we could 
very generally allow to the intellect of a person normally 4 
C. Wernicke. 
developed a settled, systematic action and conformity to 
law. Accordingly we will not be too bold, if we assume 
that in the rise of the same combination of associative ele- 
ments, the same psychical process always follows and that 
in this respect the proposition of the specific energy of the 
sense elements might be transferred to the whole organ of 
association. The way, in which the function of these local- 
ized associative colligations is set in operation, is then 
relatively of no account, under certain circumstances a 
morbid internal stimulus may cause different psychical 
processes according to its localization. From this view all 
changes in the contents of consciousness attain the value 
of focal symptoms, which naturally vary in clinical dignity, 
according as they correspond to states of irritation or paral- 
ysis, but however will behave just like the familiar focal 
symptoms in brain disease. 
Take an example from the province of brain diseases. 
A large cerebral hemorrhage from the marginal artery of 
the lenticular nucleus or an embolism of the Sylvian artery 
causes, besides a hemiplegia, at the time of the acute 
illness a number of grave attendant symptoms, which are 
to be regarded as collateral effects of the local brain injury. 
As a result of the direct destruction the hemiplegia continues 
as the residuary state, but the collateral effects disappear. 
But exactly the same sort of a hemiplegia may occur, when 
a tumor of slow growth or a chronic encephalomalacia 
destroys the same locality, usually in the way that a 
monoplegia comes on gradually, e. g., of the leg, then a 
monoplegia of the arm and finally of the facio-lingual 
region, so that a hemiplegia at last exists. Corresponding 
to this chronic course severe general symptoms may be 
completely lacking. But the location of the brain destruc- 
tion is the same in both instances, and hence the right is 
proven to compare the residuary focus with the chronic 
focus. We have equally the right to compare the residuary 
changes of the contents with respect to the localization of 
the process to the changes of the contents in chronic 
psychoses. 
As instructive as has proven the comparison taken Outline of Psychiatry in Clinical Lectures. 
5 
from the province of brain diseases, the analogy leaves 
us in the lurch, when we will employ it in another 
important question, which we now cannot avoid. When is 
a mental disease, except in cases of recovery, to be regarded 
as terminated, when as still active or progressive? In the 
residuary hemiplegia a doubt cannot exist in this respect, 
while in mental disease there is often actually great diffi- 
culty in deciding and 1 have already referred to the fact,* 
that in cases, which otherwise could be considered termi- 
nated, new psychotic symptoms, relative to the explanatory 
delusion, may occur and practically be of great importance. 
I must now remark, that this explanatory delusion is rarely 
limited to the delusion once entertained (usually that of 
persecution, see above), but is often consistently elaborated 
and new delusions may ever arise from it. This is the 
process, which as so-called systematization, has always 
been regarded as a sign of incurability—if incorrectly, as 
we shall see later. Shall we believe that this progression 
of the delusion runs parallel with a progression of the dis- 
ease process? As I have already intimated above, this is 
not to be assumed off-hand, we must rather admit that a 
change of the contents of consciousness once effected may 
have the most portentious consequences for all the rest of 
the individual’s mental life, without new morbid processes 
needing to occur in the brain, perhaps to the contrary, 
because a normal action of the intellect and strict logic is 
retained by the individual. We must soon give proper 
attention to this effect of a change of the contents of con- 
sciousness, the origin of explanatory delusions. 
It would take too long and actually anticipate a 
great part of clinical pathology, should I here under- 
take to discuss the explanatory delusion in its entirety. 
The hint is sufficient, that almost every one of the acute 
symptoms, which we will later become acquainted with, 
may be the source of explanatory delusions. Of the 
explanatory delusions of the paranoiac states only certain 
categories are here suggested. We follow the point of view) 
that they are essential in part for the comprehension of the 
*See Alienist and Neurologist, Vol. XX, p. 552, 6 
C. Wernicke. 
cases presented, will lead in part to the cognition of a 
pathological principle, a hypothesis essential and indispens- 
able for the clinic of mental diseases. 
The province of somatopsychical explanatory delusions is 
of an almost indescribable variety. We have made the 
acquaintance of an example in the patient Tschieke. Form- 
ulated at the time the supposed changes in the body are 
felt, they rarely remain so harmless as in the artless 
admirer of Haeckel. The changes, which the body has 
supposed to have undergone, are very generally regarded as 
the effect of external influences and turn the patient’s ill- 
will and hatred against persons and institutions. 1 remind 
you of Mrs. Schmidt. Another patient of this kind, whom 1 
have recently presented, manifests his indignation very 
drastically, in that he thinks he is degraded to a hog by 
this usage, he repeatedly calls himself a hog, without hav- 
ing a doubt that he does not think somewhat of a real 
change in his body, but only combines with it the trans- 
ferred significance above intimated. The real change in the 
body, of which he chiefly complains, was that his head 
would be split open by the blows of a hammer; his face 
was to be pushed down and the crown of his head shoved 
up, so that his whole head would be broader. The whole 
change could be effected quite quickly in one night. These 
changes have been undertaken; how they are to be effected 
he must leave to the physicians, for he is a layman. You 
clearly remember with what distinctness this intelligent 
patient, a merchant 27 years old, who has been insane for 
three years, developed his explanatory delusion with respect 
to its motive. He hesitates between three different assump- 
tions. It seems the most probable to him that he was to 
be made insane and in this way gotten rid of. To my 
question, if he is insane, he replies, as you recollect, that 
he considers this very possible. The other explanation, to 
which he inclines, was that the bodily abuses could be for 
the purpose of testing him and to prepare him for a higher 
calling. Perhaps the distortion of his head should espe- 
cially serve to give the external appearance of a nobieman, 
the Duke of Sagan. He adds indignantly: “But I do not Outline of Psychiatry in Clinical Lectures. 
7 
take the name, for then I would really be a hog at the 
bottom of my heart.” A third possibility is also vaguely 
entertained by the patient, namely that the purpose of such 
manipulations is to amuse other people. “Perhaps the 
whole affair is a comedy or a farce.” In the assertion of 
these three possibilities he reckons with the cer- 
tain assumption, that there is an intrigue against him. 
There is no question but that 1 will be able to pre- 
sent the same patient to you for several semesters and 
in possession of the same well retained logic and dialectics, 
and that he will then no longer vacillate between different 
possibilities, but present a well-founded single delusional 
system. Whether this will correspond to one of the possi- 
bilities now in doubt, or rather be a new, more complex 
delusional structure, cannot now be decided. The latter 
assumption is the more probable, for we now see the 
patient still susceptible to the constant correction of new 
psychotic data. The opportunity is not always afforded us 
to contemplate in a certain measure the process of systema- 
tization, as it is possible in this patient owing to his degree 
of education, his well retained logic and self-possession and 
his readiness to communicate his ideas. We generally have 
merely the completed fact of the explanatory idea, but 
without being permitted a doubt of its significance beyond 
its purport. I will now call attention to one of the most fre- 
quent somatopsychical explanatory delusions, because of its 
great practical importance. It is usually the persons in the 
nearest relation (e. g., the relatives) or the officers of the 
asylum, who are to blame for the bodily torments. In a 
patient of this kind, in whom the change of the contents of 
consciousness was of such an extent as to lead many phy- 
sicians to regard him as a hypochondriac, i. e.f suffering 
with a neurosis instead of psychosis,* his wife was to 
blame, and she must finally leave him on account of his 
insults and actual assaults. In another patient the unques- 
tionable indisposition was charged to the officers of the 
asylum, and consequently he directed all his efforts to 
secure a transfer to another institution, for he still felt too 
♦More of this case later. 8 
C. Wernicke. 
ill to dispense entirely with hospital care. 
Of autopsychical explanatory delusions we have an 
example in the patient Tschieke. She claims to think 
double since her illness, by which she understands having 
acquired the ability to talk about scientific, political matters, 
etc., as well as those relating to her cooking. 
One of the most important series of explanatory delu- 
sions of autopsychical origin, starts from the phenomena of 
autochthonic ideas, as we will call them. The patients 
notice the appearance of thoughts, which are felt to be 
foreign, not belonging to them, i. e., not occurring in the 
usual manner of association. The explanation of this 
symptom offers no difficulties, for it is exactly what we can 
expect from a morbid irritant acting on a definite locality of 
the organ of association. We may assume that such a 
morbid irritation is stronger than the normal process of 
excitement in the function of association, that it consequently 
usurps the crest of the wave of psycho-physical excite- 
ment, and deranges the otherwise systematic and normal 
train of thought. At any rate the attention is forcibly 
directed to the autochthonic ideas and they are felt to be 
annoying intrusions. In this respect they are closely rela- 
ted to the so-called imperative conceptions, also felt to be 
annoying, yet differ from them in that the latter are never 
sensed as foreign, not belonging to the personality, and 
consequently do not acquire the portentious importance in 
the whole mental life, as do the autochthonic ideas. Irre- 
spective of the fact that the derangement of association 
due to the autochthonic ideas of many patients particularly 
those finely organized, is felt to be annoying and often 
more annoying than bodily sensations and pains, they are 
almost without exception a fertile source of autopsychical 
explanatory delusions. There are only exceptionally such 
objective observers among the insane, who feel the strange- 
ness of these thoughts and do not give them any peculiar 
significance.* These thoughts are almost always “created, 
forced, suggested,” also “diverted,” by whom and in what 
*StilI there are such, as a case recently taught me. The autochthonic ideas were the 
only psychotic symptom and disappeared without giving rise to explanatory delusions. Outline of Psychiatry in Clinical Lectures. 
9 
way, depend wholly on the patient’s individuality and the 
purport of the autochthonic ideas. Religious thoughts are 
suggested by God, evil ones by the devil, enlightened 
minds use physical agencies, whose manipulations they 
usually credit to the physicians. That was the case with 
the merchant whose somatopsychical explanatory delusion 
has occupied itself with us, he complains of “foreign 
thoughts,” from which his mind suffers, and very especially, 
that his sleep is disturbed and in the beginning of his 
illness had been unable to attend to his business. Also the 
direction from which the thoughts are “forced” upon him, 
he says is from above, from the ceiling, probably in conse- 
quence of simultaneous abnormal bodily sensations. The 
patient points to the acme of the situation, in so far as he 
conjecturally explains the thoughts by suggestion and hyp- 
notism, only that the act of hypnotism was unobserved and 
performed counter to his will. You will remember how 
hard it was for me to get the patient to tell of these 
thoughts, after long solicitation only did he yield. The 
reason of his refusal was, that his thoughts must have 
been known to me. We will come across this symptom of 
so-called “thought-utterance” Gedankenlautwerdens”* from 
another source. It belongs to the most frequent explanatory 
delusions for the symptom of autochthonic thoughts, that 
the patients perceive in the physician the author of these 
thoughts and therefore suppose they must be known to 
him. The answer so often heard from taciturn patients: 
“You know that already” or “You know much better your- 
self” generally has this purport. 
You can see from this example, what an in- 
fluence the age in which we live must have on the spe- 
cial purport of all explanatory delusions. We have now no 
less than three chronic patients at the Clinic, whose 
explanatory delusion is based on hypnotism and suggestion. 
In the Middle Ages, when religious ideas, belief in miracles 
and superstition controlled the mind, a corresponding pur- 
port of the explanatory delusion was the rule, of which you 
*This accepted term originated with Cramer. Die Hallucinationen im Muskelsinn die 
Geisteskranken, Freiburg, 1889. 10 
C. Wernicke. 
can find the most striking examples in the extorted confes- 
sions of the unfortunate victims of the numerous trials for 
witchcraft. 
The same dependence of the special purport of delu- 
sions on the prevailing ideas of the age, we find especially 
pronounced in the allopsychical explanatory delusions. The 
elementary symptom, which here forms the most frequent 
starting point for explanatory delusions, is that of the 
sense deceptions, by which is understood illusions as well 
as hallucinations. In our sense the sense deceptions are to 
be defined as psychosensory hyperesthesias and paresthe- 
sias, but must defer the description of further particulars 
until later. Their effect is always to add to the contents 
of consciousness a number of false components, which 
belong to the allopsychical sphere and thus falsify it. By 
the patients they are usually regarded as singular phenom- 
ena requiring explanation, yet their reality is usually 
unquestioned, for reasons we will become acquainted with 
later. The explanation generally occurs by the assumption 
of physical agencies, of which some enemy and persecutor, 
in more rare cases a friend and protector, make use. These 
agencies vary in kind according to the individuality, and 
the system thus constructed corresponds exactly to the 
patient’s degree of education. For the explanation of 
acustic hallucinations ignorant people most commonly make 
use of an arrangement, which corresponds to the simple 
speaking-tube: Holes are either bored through the wall or 
the walls are hollow, subterranean passages exist, etc. For 
a time the telegraph played the same role in all who had 
heard of it, and now it is almost universally replaced by 
the telephone. For those versed in physics the absence of 
perceptible wires no longer offers any objection, for Herz’s 
experiments have demonstrated the conduction of electricity 
through empty space. Optical sense deceptions are traced 
to more or less complicated optical instruments, simple 
arrangements of mirrors and projection appliances being the 
most common. Tactile hallucinations lead to the idea of 
being sprinkled or powdered, usually of course with perni- 
cious substances, and if there are prickling sensations, the Outline of Psychiatry in Clinical Lectures. 
11 
majority know that it is a matter of the effect of electricity. 
Also the sensation of stabs, of being exhausted, touched on 
different parts of the body, etc., is projected outward by the 
patient. Deceptions of taste and smell will vary according 
to the knowledge and direction of the individual’s thoughts 
and the supposed effects, but are generally interpreted as 
pernicious or poisonous. The so-called delusion of physical 
persecution, of which you have an example in the patient 
Schmidt, depends, as you see, on those explanatory attempts, 
we will therefore not admit it to be a clinical form of 
disease or at least only in the same sense as every other 
kind of explanatory delusion. It must be entirely different 
criteria, which assign to the thus established delusion of 
persecution its definite position in pathology. This arises 
from the fact, that in more rare cases the same hallucina- 
tions may be construed favorably as means to impart advice, 
to exercise surveillance, to protect the body, to inure, steel 
it against villainy, etc. This cannot alone depend on the 
variously colored individual purport of the hallucinations, for 
we will learn by and by that this purport is not accidental, 
but varies according to the existing form of disease and thus 
is determined according to law. 
XII. 
SEJUNCTION hypothesis and attempt to explain 
THE SYMPTOMS OF PATHOLOGICAL IRRITATION. 
EXPLANATORY DELUSIONS IN CONSEQUENCE OF 
MOTOR SYMPTOMS AND FUNCTIONS IN THEMSELVES 
NORMAL. 
The discussion of the allopsychical explanatory delusions 
was not to be evaded here, because a great part of the 
chronic psychoses, whether temporary or permanent, is 
burdened with sense deceptions, in the first case at least 
they have the significance of corresponding to disease peri- 
ods of somewhat more acute complexion. But still, the 
second reason is to be added, that in cases of residuary 
chronic mental derangemeut the sense deceptions may be 
either permanent, only temporary or occur from definite 12 
C. Wernicke. 
causes. This seems to contradict all our premises, for in 
sense deceptions the action of consciousness is extremely 
deranged and we had accepted that in residuary paranoiac 
states the action of consciousness has returned to the normal. 
Should it not be, we will ask, the certain sign of a disease 
process still active, in the course of development, when a 
chronic mental derangement is accompanied by sense 
deceptions? That this question may be asked proves the 
difficulty which often actually prevents us from deciding 
between a residuary mental derangement and chronic 
psychoses. 
It will be well to avoid answering this until I have 
spoken of a hypothesis, which, in my opinion, can alone 
disclose the true meaning of the nature of all mental 
diseases. 1 begin with the first patient, the gardener Rother, 
who, as first stated, has at any rate occasionally, if only 
very rarely, sense deceptions. How is it possible, we ask, 
that such a large number of false ideas and opinions can 
exist in the same brain, which are so glaringly contradictory 
to the reality as well as to each other, and then with well 
retained formal logic, apparent self-possession and on the 
whole correct comprehension of the situation? In the face 
of the fact, which is undeniable, and according to the gen- 
esis of the present state, the answer may undoubtedly be: 
It was an acute mental disease, which has caused this 
looseness in the established structure of association. We 
will designate this process of disjointing by the correspond- 
ing name of sejunction and will not be able to help seeing 
in it a defect, a breach of continuity, which must correspond 
to the abrogation of certain functions of association. 
Because in the brain the different ideas and complex of 
ideas are not merely co-existent with each other, but are 
formed into large combinations and finally into the unit of 
the ego, may depend solely on the function of association. 
The fact that the patient is unconscious of the incongruity 
of his various false ideas, indicates that the combination of 
all higher unions into a unit, the ego, has ceased. If the 
man consists simultaneously in a certain measure of a 
number of different personalities, we may aptly designate Outline of Psychiatry in Clinical Lectures. 
13 
his state as “disinterigation of the individuality”. That this 
appears so little in his external manner, particularly in his 
occupation, is accidental and due to the slight demands 
which his work places on the whole personality. The 
monotonous employment of the gardener is closely allied to 
other kinds of work, like that of the farmer, many factory 
hands and persons engaged in manual labor after definite 
patterns. If it is the matter of an occupation requiring a 
very complex personality, like that e. g. of the judge, 
physician, master mechanic, the disinterigation of the per- 
sonality would be continually manifested in the vocation. 
We will see later, that the majority of all those signs 
of deranged secondary identification, which form the symp- 
toms of the acute mental diseases, are explainable by the 
same process of sejunction. Also the changes in the con- 
tents of consciousness, which may remain as sequela of 
these derangements of identification, hence be traced to 
sejunction. 
But we further know, that besides recovery and the 
residuary changes in contents, there is a third termination 
of acute mental diseases, that of dementia or mental 
enfeeblement of various degrees. But, as we will see later, 
we shall have to deduce dementia from the sejunction pro- 
cess. for we can define it only as an abrogation or blunting 
of the act of association. 
Before the termination in definite recovery a shorter 
or longer stage may be frequently observed in acute mental 
diseases, which after the decline of the acute period repre- 
sents in a certain measure its product in form either of a 
change in the contents or a quantitive diminution in the 
function of association. This stage of the acute mental 
disease, whether paranoiac or demented, is capable of 
restitution. 
All these considerations force us to perceive in the 
sejunction hypothesis the real nature of the acute mental 
diseases. As the example of Rother teaches, sejunction is 
demonstrable at once in many old cases. In other cases 
the unmistakable progression in the change in the contents, 
may lead to the same chronic terminal process, although it 14 
C. Wernicke. 
is less conspicuous. On the extent to which sejunction 
occurs, will then depend, whether the disease type finally 
passes into a state of defect, dementia. 
So we see that the sejunction hypothesis affords us the 
key to the comprehension of the chronic as well as the 
acute mental derangements, at least their most important 
symptoms, which we may compare to the phenomena of 
abrogation in brain diseases. But it is unmistakable that 
another series of symptoms is not explained, I mean those 
which we have comprehended as symptoms of irritation, like 
the hallucinations. Of these the better investigated pathol- 
ogy of organic brain diseases gives us no information, for 
the most familiar symptoms of irritation in this province, 
localized spasms and contractures, are completely unknown 
to us with respect to their genesis. We only learn from 
the brain diseases, that these symptoms of irritation are 
almost exclusively associated with phenomena of abrogation 
and thus gain their clinical dignity. In some form therefore 
a causal connection between symptoms of irritation and the 
phenomena of abrogation might be assumed. Yet in our 
province it is different, in so far as certain phenomena of 
irritation, like the halluciations, belong to the most impor- 
tant and often apparently independent symptoms of mental 
diseases. Should not the attempt be justified to demon- 
strate of them a definite dependence on symptoms of 
abrogation, i. e., here the process of sejunction? This is in 
fact a requirement, which is forced upon us by the experi- 
ences of the clinic; for we know of mental diseases, which 
present almost exclusively and in their whole course only 
these symptoms of irritation and still attain the same fatal 
termination of falsification of contents or dementia. With 
the extinction of the symptoms of irritation a defect is then 
revealed to us of an often unexpected extent. Therefore 
with all circumspection it may at least be said that the 
process of sejunction may be accompanied by symptoms of 
irritation and masked by them. It is now entirely within 
the range of prevailing opinions of disease processes, which 
destroy the nerves, that they also act as irritants to the 
nerves: the prevailing theory of the effect of irritation rests Outline of Psychiatry in Clinical Lectures. 
15 
entirely on this basis. The same opinions now obtain for 
the ganglion cells. The temporary result of the process 
leading to the death of the nerves would then have to have 
weight as decisive for the origin of irritative effects. But 
perhaps a somewhat more definite, purely mechanical 
comprehension of the irritative effect is possible. As you 
remember, we have considered the act of thinking as a 
form of movement, which proceeds in the endless associa- 
tion chain sAzm of our scheme. The memorial images 
were stations of stored energy, which are constantly charged 
from the centripetal tracts passing into the projection fields, 
A discharge of this energy continually occurs, as we may 
assume, and thus finally the charge of the projection field m, 
which qualifies it for its manifestations of force. This con- 
tinual equalization of energy is disclosed by the so-called 
unconscious action of thought and by the fact that one 
always awakens from sleep with some idea. According to 
the general principles of mechanics, it would be expected 
that the interruption of this current of energy by sejunction 
causes its regurgitation and thus a local increase of the 
process of excitement. If the “nerve current” was directly 
comparable to the movement of fluids, a reflected wave of 
the nerve current could be spoken of. But even yet in the 
ganglion cells, as the chief storehouses of energy, an 
increased tension is to be expected in deranged discharge 
and continual influx, which may readily run up the psycho- 
physical movement to a wave crest.* In this sense it is 
not perhaps too hazardous to speak of an arrest of nerve 
energy. The site of the sejunction process would then be 
decisive for the resulting symptom of irritation, and the 
occurrence of hallucinations would permit the conclusion of 
sejunction of the tracts sA, or at least in a tract relatively 
near the projection fields of the senses, for instance in the 
area of the terminal ideas A. 
In the case of the autochthonic ideas a symptom of pure 
irritation seems to be present. However the comparison 
with imperative conceptions shows particularly that this 
assumption is insufficient for the explanation of the phenom- 
♦See Alienist and Neurologist, Vol. XX, p. 538. 16 
C. Wernicke. 
enon. The patients actually distinguish very accurately 
between their own thoughts, which in the case of impera- 
tive conceptions are forced upon them against their will, 
and those that are strange and unexplainable, the autoch- 
thonic ideas. The assumption is obvious, that the 
distinguishing sign is to be sought in sejunction, so that 
first—in imperative conceptions—it would be a matter of a 
process of irritation in retained continuity, the other, in the 
autochthonic ideas, of such in partly interrupted continuity. 
The inner relationship between hallucinations and 
autochthonic ideas is placed in the proper light by this 
consideration. Both depend on sejunction processes, both 
seem to the patient like strange intrusions and are usually 
projected outward. We will have to seek the real distinc- 
tion between them in the difference of locality at which 
sejunction occurs, in hallucinations it is the tract sA, in 
autochthonic ideas the tract AZ of the psychical reflex arc. 
It is now comprehensible that the two symptoms of 
irritation are very closely related to each other clinically, 
and that transitions between both symptoms are found. 
This I can prove to you, e. g. in the case of a mechanic, 
24 years old, who has interpreted his autochthonic ideas 
soon after the beginning of his illness as inspirations of the 
Holy Spirit, but for several weeks hears the voice of the 
Holy Spirit speak. Also in the patient Bohm, according to 
his exact statement, a stage of autochthonic thoughts has 
preceded the hearing of “voices.” The fact, that the 
patients do not exactly know whether they have heard 
voices or only had the corresponding thoughts, agrees further 
to a transition stage between autochthonic thoughts and 
hallucinations. This uncertainty of the patients as to their 
own perceptions is met with very frequently. 
A second inference from our consideration relates to the 
position of hallucinations in pathology. If our hypothesis is 
correct, hallucinations may arise without a real morbid 
process existing, merely by the arrest of the nerve current 
by sejunction. In front of the site of the interruption of 
continuity an increase of the amount of irritation above the 
standard and consequently an excitement of the sensory Outline of Psychiatry in Clinical Lectures. 
17 
brain regions in S may be expected without external irrita- 
tion, especially when the same process has frequently 
occurred and has thus become habitual. 1 remind you of 
what 1 have said in my introduction about memory and 
training of the nervous system. Hence 1 have finally suc- 
ceeded in giving you a basis for our presumption above 
alluded to, that under certain circumstances the hallucina- 
tions cannot claim the significance of an active disease 
process, but are to be regarded as pure sequela of terminated 
disease processes. A clinical fact, which will occupy us 
later, appears in an especially interesting light after this 
discussion. It quite frequently occurs that the recovery from 
acute mental diseases is retarded by an intermediate stage, 
often unfortunately of very long duration, in which they 
besides the delusion of relatively—present no psychotic 
symptom other than the hallucinations. I call this condition 
residuary hallucinosis and for years at every semester have 
presented one or more examples of it. You will comprehend 
how we will have to regard this condition. The acute dis- 
ease processes are past, but perhaps the multi-topical 
sejunction has not been completely adjusted, or the patho- 
logical habit has so facilitated the recurrent movement, that 
normal amounts of irritation are discharged into the projec- 
tion fields of the senses. In such patients all intense affects 
generally produce hallucinations, exactly in harmony with 
our comprehension of the symptom. It seems to be in such 
cases in which an intercurrent, mild febrile disease may 
induce a rapid recovery. An example of the kind is a 
gentleman, who had vivid hallucinations for a long time 
after a severe acute mental disease, so that he had been 
regarded as incurable. He became perfectly well in a few 
days from influenza. 
After this digression into theory, we again return to 
the purely practical matter of symptomatology by taking up 
a further extensive group of explanatory delusions. 
The special kind of explanatory delusions, which arise 
from elementary derangements of the motor reactions*, 
♦The merit belongs to Kahlbaum of having first referred to the special derangements of 
movement in the insane; a merit, which is equivalent to that of the description of progressive 
paresis. Klinische Abhandlungen uber psychische Krankheiten, I heft: Die Katatonie, Berlin 
1874. 18 
C. Wernicke. 
deserve an intermediate position between the autopsychical 
and somatopsychical, in so far as a person’s motility is 
expressed in perceptible changes in the body, but on the 
other hand with progressive degrees of adeptness attained 
enters the more and exclusively into the service of the 
personality. At least the so-called actions, but also the 
most simple movements, which are consciously performed, 
may therefore be regarded as a function of the consciousness 
of the personality. The common hyperkinetic states need 
not now engage our attention, as they exclusively occur in 
the acute psychoses or at least not rarely in acute excerba- 
tions of the chronic psychoses. While parakinetic and 
akinetic states are quite common events in the chronic psy- 
choses, and their more isolated occurrence (limited to definite 
muscular areas) then corresponds to a slow aggregate of 
focal symptoms. At present we will discuss the subject 
only so far as it is essential for the comprehension of the 
explanatory delusions thus originating. The independent 
origin of symptoms of akinetic and parakinetic motility 
induced by the normal mechanism of association, belong to 
the most instructive examples of the sejunction process. 
What was said of autochthonic ideas and hallucinations, 
namely that they are sensed as processes foreign to the 
personality, affords us a key to the explanatory delusions 
of this origin. I remember an old patient, whose constant 
occupation consisted in walking in a circle of a few feet in 
diameter and in turning corresponding to its axis. The 
explanatory delusion combined with it was that she was the 
earth and must turn. Such a fanciful delusion adhered to 
in states free from affect, we will naturally meet with only 
in patients of long standing with variously changed contents 
of consciousness. But is it very much less strange, when 
a very recent patient claims it must be a machine hidden 
within him, which continually turns him around in a circle? 
Of course in such cases magnetic and electrical forces are 
especially charged with being the operative agent. Much 
more rare, but just as evidential are tlie parakinetic symp- 
toms described by the patient, without an explanatory 
delusion being associated with it. Thus a patient began to Outline of Psychiatry in Clinical Lectures. 
19 
sing during the clinical presentation, and you remember 
how clearly she expressed herself, that it was against her 
will and she could not help it. It is the same patient, in 
whom 1 could demonstrate another interesting phenomenon: 
she usually presented the faulty type of respiration, which 
I designate as insufficiency of the phrenics, i. e. her epigas- 
trium is retracted during inspiration and the normal expan- 
sion of the lower chest wanting. While in singing she 
presents all at once the normal type of respiration. That 
the interpretation of this symptom on the basis of the 
sejunction hypothesis is possible, 1 believe 1 demonstrated 
to you then. Similarly conspicuous by the absence of an 
explanatory delusion is the example of a lady, whom I am 
now treating. She has to cry periodically, as well as laugh, 
without the corresponding affect, and especially complains of 
the “silly laughing”, during which she might be really 
considered demented. In these cases it is a matter of the 
decline of a subacute psychosis which was distinguished by 
a sort of mutual disjointing of psychotic symptoms following 
each other and advanced to the delusion of retrospective 
relativity*. These examples, although not related to our 
theme, may still be given a place here, to show you the 
symptom in its purity. They are very frequently express- 
ive movements, which occur in the way, then simpler ones, 
like the facial distortions of anger, menaces with the fist, 
ejaculation of plaintive tones, wringing the hands, etc., but 
often complex attitudes and movements, like the attitude of 
movements of attack of all kinds, dancing and the 
like. Such complex kinds of movement, like those of drill- 
ing, describing a circle, (see above) fall more into the 
category of initiative movements. As soon as such move- 
ments are permanently established, corresponding explana- 
tory delusions seem to always originate, and these form the 
rule, as 1 have already intimated. The purport of the 
explanatory delusion is either more dependent on the fact 
or on the form of the movement. The delusion of physical 
persecution derives its material in part from these paraki- 
netic states, then the belief in supernatural agencies, either 
*See below. 20 
C. IVerniche. 
good or evil, of being possessed, quiet frequently also the 
idea of being transformed into an animal. The latter idea 
leads especially to the utterance of inarticulate growling, 
movements of biting and contortions of the face and an 
animal-like use of the extremities, e. g., walking on all 
fours. In the chronic psychoses, when these parakinetic 
states occur only for a short time, the explanatory delusions 
are likewise of short duration, at most it occurs that sub- 
sequently the memory of such explanatory delusions 
occasionally reappears in the form that the patient believes 
he has passed through some animal transformations. 
It quite often occurs that wholly isolated movements, 
generally of the character of the reactive, have become 
fixed and habitual in the patients, so that they cling to 
them all the rest of their life. The more or less silly, 
eccentric expressions and gestures of the old insane cases 
often depend on such acquired habits. 1 know an old 
patient, who, when conversing, turns up the right upper 
eyelid with the index finger of the right hand, evidently 
the residue of an original parakinesis due to abnormal sen- 
sations, then psychosensory. Another patient, whom you 
have recently seen on the ward, generally places the hand 
to the side of the head while talking, and you remember 
still another, who has the habit of holding the hand over 
the mouth while speaking. In all these cases the move- 
ment is wholly unconscious, at any rate motiveless, and the 
patients can give no reason, when their attention is called 
to it. The “crazy” appearance of many old insane (apparent 
to the laity) depend on such peculiarities. Explanatory delu- 
sions of various sort may start from them. 
Of akinetic states the same is true with respect to the 
extent of the phenomena as of the hyperkinetic, i. e., states 
of general immobility should occur only very exceptionally 
in the chronic psychoses, while they seem to be the pre- 
rogative of the acute and subacute. When they occur they 
seem to be of psychosensory origin, as in the well-known 
example in literature of the man, who avoided every 
movement, because he believed he had an infernal machine 
in his body, which might be thus exploded, and similar Outline of Psychiatry in Clinical Lectures. 
21 
seems to be the example of the woman who claimed she 
was of glass and feared being broken by movement. But 
perhaps it is merely a matter of residues of acute motor 
psychoses in these notorious cases. Whereas in the chronic 
psychoses parts of motion are seen to be quite often 
affected. These partial akineses are largely of psycho- 
sensory origin, like the inability to swallow, which may 
produce the symptom of refusal of food in cases of an 
entirely chronic course. The attendant sensation is gener- 
ally described as closure of the throat, and to it independent 
explanatory delusions of somatopsychical sort may be added. 
Next to the refusal of food, mutism is the most frequent form 
of circumscribed akinesis, and also of psychosensory origin 
in a part of the cases. Such patients occasionally commu- 
nicate in writing that their tongue seems to them entirely 
gone, or that it is swollen, paralyzed, withered or perfectly 
stiff, but the sensation extends beyond the tongue, for in 
such cases the accompanying movements of the lips are 
often absent also. Another time the symptom is of 
pronounced psychomotor sort, for sensations like those first 
described are expressly contradicted. Mutism and refusal 
of food often occur in combination. These circumscribed 
akineses of psychomotor origin are often due to prohibiting 
“voices,” and that here the hallucinations have no other 
significance than of terminal ideas put into words, is shown 
by instructive examples, in which the force of direct phys- 
ical influence on these movements is ascribed to the voices. 
The explanatory delusions following, that certain persons, 
whose voice they recognize rob them of speech or prevent 
the taking of food, then seem readily comprehensible. 
Although the diffused states of immobility, as 1 have 
intimated, do not really belong here, yet as the source of 
various explanatory delusions, they therefore deserve a pre- 
liminary consideration, because they occur preferably in the 
acute excerbations of the chronic psychoses. The supple- 
mentary explanation of such states very commonly is, that 
the patients believe they have once been dead and again 
returned to life. The restoration of the ability to move is 
generally conceived as a matter of resurrection, and all 22 
C. IVerniche. 
these explanatory delusions of a religious nature, which are 
suggested by the comparison with the sufferings and death 
of Christ, are associated with it. The patients often con- 
sider themselves the returned Messiah. If it does not 
amount to this idea, the related one of prophecy readily 
originates: the task of redeeming the world by reason of 
the supernatural occurrence presumed to be so similar to 
the passion of Christ. In other cases the fanciful explana- 
tion of the akinetic states is especially colored by the 
memory of visions and vague hallucinations, which have 
existed during them and usually have an ecstatic, religious 
purport. It does not need to be especially emphasized, 
that the state of consciousness at the time of the akinetic 
states cannot be directly established, but is subsequently to 
be disclosed by the communications or conduct of the 
patients. Still so much is certain, that it is a matter of 
very different states, among which the akinetic phenomena 
may take a perfectly independent position. 
In other cases one hears from the patients, as soon as 
they have awakened from their motionless state, that they 
were subjected to the most heterogeneous morbid sensa- 
tions, pains of unbearable intensity, cessation of the heart’s 
action, suffocation, stagnation of the blood in all the veins, 
etc. It is then a matter of a state of psychosensorially 
induced akinesis. Occasionally the patients describe their 
sensations as a continual death struggle. The hypochon- 
driacal feelings are quite often accompanied by adequate 
cutaneous sensations and hallucinations of sight, as e. g., 
the feeling of dying from hemorrhage and the visual hallu- 
cination of pools of blood in the bed. These combined hal- 
lucinations are, as we shall see later, quite common in all 
states of blunted sensorium. It is conceivable what a fer- 
tile source of explanatory delusions is afforded by one of 
these periods of suffering. Here the comparisons with the 
sufferings of Christ or some martyr immediately follow and 
most commonly the grandiose delusion of being a savior or 
prophet is associated. 
It is not always true psychotic symptoms, which cause 
explanatory delusions, it may be the normal processes of Outline of Psychiatry in Clinical Lectures. 
23 
the organism, some real functional derangements, which of 
themselves would be of only slight importance. The inti- 
mate relation is here displaced, in so far as the explanatory 
delusions then have no independent significance, but occur 
only in conjunction with other delusions already existing, 
and in a certain measure serve for their elaboration. Of 
the wholly normal processes sleep is to be mentioned first 
of all. A profound sleep, which happens at the time new 
changes in the contents occur, is very often regarded by 
the patients, that they could have been stupefied to permit 
such manipulations. The feeling of pregnancy manifesting 
itself may in part be interpreted in this way, and the 
counter idea, that a cohabitation has not occurred, may thus 
be explained. But allopsychical changes in the contents of 
consciousness also lead to delusional interpretation of sleep: 
the patient has been stupefied and in this state taken into 
strange surroundings. It is very similar, when the experi- 
ences of a dream are recognized as such, but are still held 
to be divine inspirations. Of the actual functional derange- 
ments, but delusionally interpreted, the disturbances of 
menstruation and pregnancy deserve special mention, then 
intercurrent dyspepsias and digestive derangements, as well 
as the constipation often actually present in the hypochon- 
driacal. You see the tendency once present to systematiza- 
tion of a delusion is abundantly supplied with material for 
utilization by the normal or approximately normal processes, 
and that here also the occurrence of explanatory delusions 
furnishes the means to fill the consciousness with a number 
of false ideas. 
(To be Continued.) IF YOU ARE 
AN ADVANCED PHYSICIAN or 
PROGRESSIVE LAWYER, 
YOU CANNOT DO WITHOUT THE 
ALIENIST NECIR0L0QIST. 
r HE ablest men in Neurology and Legal Medicine subscribe and 
I write for it. 
M The morbid movements of the mind, brain and nervous 
system are mirrored in its pages by master minds in medicine. 
It constantly gains and seldom loses subscribers. 
ADDRESS H# L# HUGHES, M. D., 
MANAGER AND PUBLISHER, 
3857 Olive Street, $5.00 Per Annum. ST. LOUIS, MO. OUTLINE OF PSYCHIATRY IN CLINICAL 
LECTURES. 
(CONCLUDED). 
PARANOIAC STATES. 
DR. C. WERNICKE, 
Professor in Breslau. THE 
Alienist and Neurologist. 
VOL. XXL 
ST. LOUIS, APRIL, 1900. 
No. 2. 
OUTLINE OF PSYCHIATRY IN CLINICAL > 
LECTURES.* 
(CONCLUDED). 
PA RA NO I A C ST A TES. 
By DR. C. WERNICKE, 
Professor in Breslau. 
HALLUCINATIONS OF VOCAL SOUNDS OR PHONEMES. 
DELUSIONS OF RELATIVITY OF AUTOPSYCHICAL, 
ALLOPSYCHICAL AND SOMATOPSYCHICAL ORIGIN. 
Xlll. 
In the large role, not readily overestimated, which the 
sense deceptions play in the symptomatology of mental 
diseases and, as you have seen, in part in the terminated, 
it will be permitted to take up the theory of sense decep- 
tions first, that which is the most essential for their under- 
standing and clinical valuation. We still hold to the above 
explained sejunction hypothesis, without thus wishing to 
claim, that this is the only mode of origin of sense 
deceptions. On the contrary we will later encounter sense 
deceptions which very probably owe their origin to a 
primary stimulation of the projection fields of the sense 
centres, and will have to admit that the real causa efficiens 
and the point of attack of the stimulus must be sought in 
the projection fields, no matter whether these are primarily 
affected by a morbid irritation or first in consequence of a 
sejunction process and the hypothetically tenable, thus 
resulting regurgitation of the nerve current from complex 
♦Translated by Dr, W. Alfred McCorn, Resident Physician "River Crest,’’ Astoria, 
L. I., New York City, 
r-» T 2 
Outline of Psychiatry in Clinical Lectures. 
associative structures. But we may now claim that the 
sejunction hypothesis is probably accepted for the large 
majority of sense deceptions, which here chiefly occupy us, 
those of the paranoiac states. 
Certain fundamental attributes of hallucinations may be 
directly derived from our hypothesis. The first of these is 
the incorrigibility of hallucinations. We see that the reality 
of a sense deception is adhered to against the evidence of 
all other senses and that ere the fanciful explanatory 
attempts are made and the truth of the sense perception is 
doubted. This phenomenon is perfectly comprehensible, 
when it is realized, that once the morbid irritation engages 
the attention, i. e. monopolizes the wave crest of the 
psychophysical movement, which in itself owing to the 
narrowness of consciousness renders the momentary correc- 
tion impossible, but besides that the only means which is at 
command for correction through the other senses, the 
association with the normal ideas excited by them, or in 
other words the awakening of remonstrances, is made diffi- 
cult by sejunction or entirely impracticable. 
Exactly the same consideration also explains the cogent 
character of such hallucinations, which have an imperative 
or prohibitory purport. Here also the remonstrances are 
inaccessible through the fact of sejunction, so that the 
nerve current, confined in a narrow preformed channel, is 
discharged with elementary force to the motor projection 
fields. Yet 1 cannot forego remarking, that the cogent 
character of this sort of hallucinations is usually overesti- 
mated, and that often enough patients are found, who 
resist the hallucinated demands and even complain about 
them. So e. g. the hallucinated challenge to strike the 
physician rebounds harmlessly owing to the patient’s 
attachment. But this circumstance may be explained, as 
very evident, by varying extent of the sejunction. 
A second remarkable fact is the predominance of the 
acoustic hallucinations and those of speech exclusively termed 
“voices” by the patients, for which owing to their special 
clinical dignity the special name of phonemes is justified. On C. Wernicke. 
3 
the other hand acoustic hallucinations may not occur more 
frequently than those of the other senses; but that the 
patients in a large number of cases exclusively hallucinate 
the vocal sounds, and in all with hallucinations, with few 
exceptions,* the hallucinated vocal sounds dominate, must 
be considered one of the most fundamental attributes of 
sense deceptions and may finally be traced to the mechanism 
of their origint. We remember we have evolved the nature 
of secondary identification in the example of the sensory 
projection field of speech. The clang image of a word heard 
does not suffice for its comprehension, but by it first the 
memorial image constituting the concept must be excited, 
thus secondary identification occurs, i. e. the sense of the 
word is understood. Although we have generalized this one 
example, it cannot be misconstrued, that the sensory speech 
center has especially intimate relations of association to the 
components of the simplest associative connections, the 
concrete concepts. It has gone so far as to put clang image 
and concept on a par. But for a mechanical comprehension 
of the processes taking place in hallucinations, it must be 
immediately evident, that with no other sense does there 
exist such an intimate colligation of some concrete concepts, 
as with the sensory speech centre. The experiment teaches 
that the time of a concrete thing which, as we will assume, 
possesses five different sense qualities, can be immediately 
found by each of these with exclusion of all the other 
senses. If we then assume the existence of suitably worn 
associations between the acoustic speech centre, and each of 
the five sense projection fields, we will comprehend, that by 
a central excitation of the concept by arrest of nerve energy 
the process of excitation encroaches on the sensory projec- 
tion field, will here be increased five fold and in this way 
*These relate to certain toxic psychoses, like delirium potatorum and several others, 
fin my opinion there is no occasion to refer the explanation of "hearing voices” to 
hallucinations of the muscle sense, as Cramer does. The symptom of "thought utterance” 
(Alienist an d Neurologist, vol. xxi, p. 9) should be restricted as much as possible and 
understood in the sense that the patients’ own thoughts recognized by them as such becomes 
naudible on definite occasions, as e. g. when they read or write. Cramer and his follower 
have unfortunately carried the symptom so far that it has entirely lost the original value of 
a elementary symptom and now always needs an explanation according to its mode of origin. 4 
Outline of Psychiatry in Clinical Lectures. 
that intensity of morbid irritation gained, which we must 
demand for the occurrence of a hallucination. Like favor- 
able conditions are again found in no other sensory projec- 
tion field. 
In the psychophysiological introduction you were told 
that individual variations may be assumed in the respect 
that, first more the meaning, then more the thought prevails 
in words, i.e., vocal sounds. Yet I believe I must caution 
you against assuming that thought only occurs in vocal sounds, 
as is claimed by many. But if we grant the probability of such 
an individual difference in thought mechanism, we have the 
key to the comprehension of an important clinical fact, 
namely the almost universally recognized experience that 
one and the same form of disease, e. g., a simple acute 
depressive psychosis, in which a definite purport of the 
intellect is correspondingly conditioned, produces in one 
individual only ideas of this purport, but in another 
phonemes of like purport. In our example then first 
exist only ideas of anxiety or ideas of fear, as 1 call 
them, another time alarming and threatening phonemes, i. e. 
the same ideas are in a certain measure put into words. 
But by no means do we meet with this experience only in 
the acute psychoses, but equally in those of slow, chronic 
origin and course. The increased nerve energy in individuals 
disposed to hearing voices, incidentally the largest number, 
in a certain measure meets with a greater excitability of the 
sensory speech field and the tracts uniting in it. 
In many chronic insane the hallucination of vocal 
sounds of special form is observed: they believe they hear 
long conversations. The patients often have a certain 
fondness for such hallucinations, evidently finding in them 
the best amusement and occupation. Probably there are 
always individuals, whose intellectual action habitually 
happens with the rise of word clang images. 
I have repeatedly intimated that the purport of halluci- 
nations is not usually accidental, but dependent on other 
conditions more or less familiar to us. This is especially 
true, as was to be expected, of the phonemes. As 1 have C. Wernicke. 
5 
already mentioned, the ideas of fear, commands and orders, 
which are usually embodied in “voices,” so we will 
later meet with the grandiose ideas of maniacs and 
the self-accusations of melancholiacs in the form of 
sporadic voices. It is very similar with the explanatory 
delusions of the paranoiac states. They very commonly 
occur in form of voices and make us understand that the 
purport of the voices is very often threatening, insulting, 
thus corresponding to the ideas of persecution, which so 
often form the contents of the explanatory delusion. No 
less do we meet phonemes of the purport of grandiose 
delusions, when the need of explanation has led to 
the evolution of a consecutive grandiose delusion. 
The same phenomenon of sense deceptions, which 
we formerly became acquainted with as a source of the 
explanatory delusion, meets us here in the entirely different 
significance, that it puts the explanatory delusion into 
words and forcibly supports the sense perception. The 
delusional conception of the world thus gains new roots for 
its energy. Still the same elementary symptom of the 
phonemes acts more portentiously in the frequent cases, in 
which it is not recognized as something strange, requiring 
explanation and not designated as a“voice,” but is projected 
to persons about. This severe stage of phonemes seems 
especially to be the expression of the delusion of relativity, 
of which 1 will soon speak. 
Although this is not the place to go into the theory of 
sense deceptions fully, 1 must yet say in anticipation, that 
we have to think the process of irritation, which here takes 
place as. encroaching on those elements of the sense projec- 
tion fields, which we have formerly distinguished as 
perception cells* and belong to the consciousness of the 
body. Only by the fact that these cells, always belonging 
to a definite area of surface of the body, are excited, can we 
explain the chief attributes of hallucinations to be studied 
later. The distinction then from the true sense perception 
*See Alienist and Neurologist, Vol. XX, p. 364. 6 
Outline of Psychiatry in Clinical Lectures. 
is limited to the fact, that in this the cause of the irritation 
lies in the periphery, in hallucinations in central—transcor- 
tical—stations, while its real point of attack is the same in 
both cases. We have seen in the introduction, that all 
intense sense excitations coming from the periphery are 
simultaneously accompanied by a tone of feeling, and under- 
stood as the sign of an affection of the body.* The 
movements of defense, which follow the sense irritation 
accompanied by an intense tone of feeling, we have become 
acquainted with as a means for protecting the body, which 
in part indicate a very remote derivation. It is now of 
great interest to learn, that in the chronic psychoses some- 
thing very similar occurs, only that the tone of feeling is 
not thus conditioned by the intensity of the sense irrita- 
tion—on the contrary it is a matter of the most ordinary 
sense perceptions and most reliable according to their 
purport—but very probably forms the element superadded 
by the mental disease, accessory to the sense perception 
in itself normal. This tone of feeling of indifferent sense 
perceptions leads to a falsification of secondary identification 
in the sense, that under all possible explanations is favored 
with respect to their own person—Neisser’s morbid relation 
to self—and in this way to the origin of delusions of 
relativity. The so-called delusion of relativity is, somewhat 
like the delusion of persecution, only a collective name for a 
copious assortment of delusions, but which are here regularly 
united to the act of perception and occur with it; it consists 
in a falsification of the perceptions themselves. Examples 
may illustrate the symptom. A person on the street finds 
the doings of others natural and of no importance. But the 
insane person with the delusion of relativity, observes that 
persons stop on his account, step aside, make some gestures. 
If they spit, they do so in front of him, if they speak, they 
speak about him, if they wait, they wait for him. The 
person coming wants to meet him, the one behind is 
following him, accidental glances, the actions of strangers 
refer to him. Undoubtedly the sense perception is correct, 
*See Alienist and Neurologist, Vol. XX.,p.356. C. Wernicke. 
7 
only the relation to themselves, which inseparably adheres 
to the perception, is morbid, like sense irritations accom- 
panied by intense tone of feeling. 
With respect to the explanation of the symptom, we 
will follow the path which has led us to the comprehension 
of hallucinations. With these the symptom has evidently a 
close relationship, and the relation to them may perhaps be 
expressed: that delusions of relativity depend on an increase 
of morbid irritation, which acts on the same area as in 
hallucinations, but does not become as intense as is essen- 
tial for the production of hallucinations, therefore the 
symptom is always manifested in connection with true 
sense perceptions. We will naturally derive the increase of 
irritation from sejunctive processes of the some locality, but 
of less intensity than in hallucinations. For such a concep- 
tion the experiences of the clinic afford us the best proof. 
In wholly chronic psychoses of an ascending course the 
first stage usually consists of such a delusion of relativity, 
it is then followed by a stage of hallucinations and 
largely of phonemes and it is very characteristic that the 
purport of the phonemes consists in by far the greater part 
of delusions of relativity. At any rate the delusions of 
relativity do not generally cease as soon as phonemes of 
like purport have been associated, but they usually continue 
in like intensity. But it now follows that the increase of 
morbid irritation exists permanently, but the phonemes, 
wliich in such cases generally occur only intermittently, 
require a special augmentation of the quantity of irritation 
for their manifestation. The residuary hallucinosis* accom- 
panying the delusion of relativity is likewise evidential. 
Here also the purport of hallucinations of hearing is largely 
derived from the delusion of relativity, and after the decline 
of the phoneme the delusion of relativity may continue 
alone for a time. 
The conditions for the occurrence of delusions of rela- 
tivity are not entirely peculiar to mental diseases alone. 
Very typical examples may be drawn from normal mental 
*See Alien stand Neurologist, Vol. XXI.. p. 17. 8 
Outline of Psychiatry in Clinical Lectures. 
life. The novice, who appears for the first time in a dress 
suit and white gloves, may readily believe all eyes are 
fastened on him, and it is similar with the young man 
when he enters the ball room for the first time, and there- 
fore behaves so awkwardly. An excellent example of this 
sort of the delusion of relativity is drawn in a masterly 
manner by Dostojewski’s pen when his hero Raskolnikow, 
conscious of the murder perpetrated, finally betrays himself by 
the references to this act, which he finds in unimportant 
expressions and meetings. When anyone perceives inten- 
tional discourtesy in an omitted salutation, it is the rise of 
a delusion of relativity. 
The first cited examples of delusions of physiological 
relativity—or ideas of relativity, if it is wished to dispense 
with the term delusion in this connection—show us the self- 
perception of a change in the personality to be the 
originating cause; this mode of origin we may distinguish as 
the allopsychical mode of origin of the delusion of relativity. 
It is an emotional state, which seems to be essentially 
dependent on the fact that the contingent change in the 
contents of consciousness is felt to be somewhat strange, 
not belonging to it, is not assimilated, digested (sit venia 
verbo), in a word, that the new experience meets with 
difficulties in association. The mental condition of a Ras- 
kolnikow would be impossible in a brutal habitual criminal. 
As in these examples taken from the normal, the delusion of 
autopsychical relativity of the insane also shows the pecu- 
liarity, that it is manifested preferably with respect to very 
definite ideas or groups of ideas. There is then a delusion 
of circumscribed relativity of autopsychical origin. In certain 
quite frequent cases of chronic mental diseases, one of 
these delusions of circumscribed relativity besides a definite 
quantivalent idea form the only two psychotic symptoms 
decisive for the origin of the mental diseases to which 
subsequently a long chain of explanatory delusions and 
analogous secondary symptoms may be added. 1 will return 
to these cases later. We meet with an extended delusion 
of autopsychical relativity, when the patients think the C. Wernicke. 
9 
occurrences of the world, which they see, or spoken sounds, 
which they hear, relate to their thoughts. Instead of actual 
sense impressions optical hallucinations or phonemes may be 
the basis of this delusion, and preferably the explanatory 
delusion, that their thoughts are uttered, i. e. have been 
heard, without their having been spoken, follows. The 
patients very readily come to this conception, when the 
phonemes represent answer to interrogatory thoughts or 
relate to answers only thought of. According to the state- 
ments of good observers, it is unquestionable among the 
insane that the phenomenon of “thought utterance”* quite 
often has this origin. 
Analogous to the delusion of autopsychical relativity we 
may then speak of a delusion of allopsychical relativity, when 
the consciousness of the world is proven to be changed. We 
will take up these cases under the acute psychoses. Another 
time an allopsychical falsification of consciousness is not 
directly demonstrable, but the symptom characterized in that 
the allopsychical mode of origin is not to be doubted. The 
recently mentioned examples are included here. 
We finally properly distinguish a delusion of somatopsy- 
chical relativity, when unimportant sense perceptions are 
referred to subjective perceptions of morbid sensations or 
other changes in the body. The examples here included 
may in part be also referred to the somatopsychical explan- 
atory delusion, but in part differ from it, when the assump- 
tion of a special tone of feeling to the unimportant sense 
perceptions seems requisite for the comprehension of the 
accomplishment. A typical example of this has become 
known to me by an opinion presented for revision, which 1 
will briefly cite to illustrate the symptom. A young man 
was brought before the court for having made a murderous 
attack on his father while he was asleep in bed. He frankly 
admitted being extremely embittered against his father and 
had intended to actually injure him without murdering him. 
The cause of his exasperation consisted of the observations, 
*See note on page 3. 10 
Outline of Psychiatry in Clinical Lectures. 
which he described as follows. It was quite common, while 
they sat at the table to get into a quarrel, in which the rest 
of the family had taken first his part, then the father’s. It 
then often happened that his father rapped on the table and 
he was thus violently excited sexually. Also in the fields, 
while at work, his father had now and then appeared, and 
thus excited him sexually. The sight of his father was 
evidently accompanied by a morbid tone of feeling, which 
in this case started from definite, but in themselves uncertain 
morbid bodily sensations. These examples have been well 
designated reflex hallucinations (Kahlbaum)* and the best 
known are those in which the insane claimed in the dishing 
out and division of the soup, they were dished out, in 
lighting the fire, they were burned, etc. The name seems 
to me but little adapted, because morbid bodily sensations 
are states analogous to hallucinations, but yet must be 
differentiated from them practically.t The delusions of 
somatopsychical relativity are very frequently found in acute 
psychoses, but they play a large role in the chronic, be it 
that they are previously connected with a chronic somato- 
psychoses, be it that in the subsequent course of a chronic 
progressive psychosis, somatopsychical symptoms are added or 
an otherwise stationary state experiences an acute excerbation 
by the intercurrent appearance of morbid bodily sensations. 
The so-called hypochondriacal delusion of persecution, to which 
a consecutive grandiose delusion may be subsequently 
associated, springs from these delusions of somatopsychical 
relativity. In every insane asylum there is a number of 
these patients, who by occasional outbreaks of violent curs- 
ing, disturb the quiet and are proven to be due to delusions 
of somatopsychical relativity. 
*Die Sinncsdeliricn. Allg. Zeitsch. f. Psych. Bd. 23, p, 1—86. 
fThis same objection may be raised against Cramer’s so-called hallucinations of the 
muscle sense. C. Wernicke. 
11 
XIV. 
THE RETROSPECTIVE EXPLANATORY DELUSION. THE 
FALSIFICATIONS OF MEMORIES. 
The sejunction hypothesis evidently shows us the way 
to acquire a mechanical understanding of the psychotic 
symptoms. As in brain diseases, it comes to light on deeper 
penetration into the nature of mental diseases, that the 
abrogation of function offers us the most valuable means for 
the understanding, while the processes of morbid irritation 
underlie-the complex conditions and must be considered 
somewhat dependent on the phenomena of abrogation. We 
will not be able to too carefully bear in mind the theory of 
brain pathology in this relation. In the light of our hypoth- 
esis, the case, with which 1 began our clinical demonstration, 
becomes clear and with the mechanical conception of morbid 
processes in the organ of consciousness,exclusively composed 
of nervous elements, appears more consistent. 
We had designed to study next the changes of con- 
sciousness with respect to contents. As the process, by 
which they arise, we had designated the acute and chronic 
mental diseases, and estimated its reciprocal position to the 
facts of brain pathology. We now believe to know that 
sejunction or disjointing of association is the chief process 
in changing the contents of consciousness. We may now 
define mental disease as the time in which by disease of 
the nervous parenchyma disjointings of associations occur. 
Thus the destruction of nerve structures, symptom of 
abrogation, is put in its proper place, without the possibility 
of restoration by regeneration, which occurs very frequently 
in the peripheral nervous system, being anticipated, or by 
commencing new associations. On the contrary, we will 
have to consider the curable acute mental diseases as 
instances of such restoration or re-adjustment. Evidently the 
disjointing of association under certain circumstances is 
equal to the destruction of certain psychological unions. So 
we will subsequently be able to maintain a loss in concepts 
or, in other words, a reduction of the number of concepts as 12 
Outline of Psychiatry in Clinical Lectures. 
a state of defect occurring in consequence of mental diseases. 
But we have next to become acquainted with and 
understand by the sejunction hypothesis other clinical 
symptoms, which we observe daily in the so-called old 
cases. To these belong first of all the subsequent correc- 
tion of the contents of consciousness or the retrospective 
explanatory delusion. In terminated cases, those chronic 
from the beginning or finally in acute mental diseases, 
which have reached a chronic stage, we see this process 
being constantly consummated in the same way. The 
changed contents of consciousness must be brought into 
harmony with the old, still unchanged possession, corre- 
sponding to our controlling requirement of causality. The 
more self-possession is again attained or, in the chronic 
psychoses, retained, the more the intellect acts along the 
lines of the strict standard of logic, then the more impera- 
tive is the necessity of emphatic, decisive arrangement being 
established in the structures deranged by the disease. In 
the complex brain mechanism not the remotest corner shall 
normally exist, which does not functionate under its influence 
in harmony with the function of all the other parts. An 
example will best illustrate the process, which then occurs. 
You remember the patient, a Doctor of Philosophy, whose 
explanatory delusion was constructed on the theory of sug- 
gestion and hypnotism. This patient has passed through 
an attack of mental disease eight years before, but had so 
far recovered, that for many years he had perfect apprecia- 
tion of the symptoms of his acute mental disease. When I 
recently presented him in a new attack, to my great sur- 
prise, the curious phenomenon presented itself, that his 
appreciation of his illness was entirely lost, so that he now 
claimed the elementary symptoms of his first sickness, 
chiefly phonemes, had not been the result of a disease, but 
the hypnotic influences of some persecutor. But of the 
circumstance that he had for many years regarded his 
hallucinations of hearing to be manifestations of disease, he 
remembered perfectly, but he very correctly remarked, that 
such a fanciful appreciation of disease could be explained by C. Wernicke. 
13 
the action of suggestion. You perceived from this example, 
with what readiness opinions, which could have been so 
firmly held for years, as they were difficultly acquired and 
the product of a complex intellectual process, can be over- 
thrown by a presumable new insight, but which is morbid. 
Nevertheless if we, as I do not question, must conceive this 
process not to be morbid in itself, but merely as the reaction 
of a normally functionating brain mechanism to the once 
existing change as to contents, you will not think it strange, 
if very commonly the defective physical knowledge of the 
majority of the insane does not hold out in the hallucina- 
tions against the evidence of their senses, when the 
assumption of a supernatural action, subterranean passages, 
hollow walls, etc., which is made for the explanation of 
strange subjective sense perceptions, loses the peculiar and 
grotesque character, which they would have according to the 
judgment of the same person when well. Previously 
acquired facts are quite often modified in the way, that 
hindrances, which heretofore oppose the solution of a prob- 
lem, e. g.f perpetual motion, like the assurance of the 
constancy of energy, are now null and void, and so are 
explained many wholly insane inventions and discoveries. 
The previous personal experiences generally form the 
special object of these interpretations. Under the newly 
acquired, presumably better insight evidences of favor 
appear like hypocrisy and cunning calculation, hostile acts 
as deeds of benevolence, non-essential occurrences as 
extremely important events, an accident as intentional action 
of some patron or adversary. 
This process of subsequent correction attains a special 
importance, as soon as it is not limited to facts, opinions 
and complex conclusions, but is extended to the memorial 
images of previous perceptions and in this way effects a 
subsequent falsification of secondary identification. This 
sort of subsequent correction of former memories we w.ll dis- 
tinguish as delusion of retrospective relativity. It is hence a 
matter of occurrences, which at any rate have analogies in 
normal mental life. It may happen to anyone, that he first 14 
Outline of Psychiatry in Clinical Lectures. 
subsequently believes to remember having met an acquaint- 
ance, who was not noticed at the time because he was 
inwardly occupied. This subsequent identification may be 
false as well as correct as to its contents, and normally this 
fact is to be taken into account. Among the insane there 
are often persons, who are subsequently identified, in whom 
the most superficial similarities generally suffice for the 
explanatory requirement. In patients with fixed grandiose 
delusions these interpretations are observed very frequently, 
even in the memories of youth. The patient remembers, 
e. g., when a boy of having been once spoken to by an 
officer; this officer was, as he has subsequently recognized 
from the resemblance, Emperor William, Emperor Frederick 
or some other noble and popular person. At the same time 
he had been asked by the teacher at school, if he still had 
a father or grandfather. This question is referred to the 
same person and should intimate where he is to look for 
his father or grandfather. The reply, that this might have 
been an indifferent question, these patients confute by 
referring to a meaning glance or significant movement of 
the teacher’s hand on this occasion, a clear evidence that 
the perception has been falsified in the memory. From 
patients of this category stories for hours are often heard of 
their youthful remembrances, which in the greatest part are 
related just as they have been experienced. But the 
perceptions universally present that coloring, which a dis- 
tinguished psychiater has aptly described by the words (itua 
res agitur.” 
In ignorant and undiscriminating persons, who are not 
accustomed to separating their subjective impressions from 
the material of objective perceptions, the delusion of retro- 
spective relativity may readily lead to wholly false repre- 
sentations, and it will often be hard, under these conditions, 
to ascertain the fact, as it has really happened. Still the 
clinical requirement demands the accurate differentiation of 
delusions of retrospective relativity from another elementary 
symptom, which is observed in the same category of insane, 
that of the so-called falsification of memories. This symp- C. IVernicke. 
15 
tom may occur in two equally significant modifications, a 
positive and a negative. The positive form of the falsifi- 
cation of memories* is also called confabulation and consists 
in the appearance of remembrances of events and occur- 
rences, which have never happened. If the purport of this 
confabulation is generally so significantly colored, that it 
corrresponds to the prevailing delusion, it then affords, e. g., 
in the cases of fixed grandiose delusion citedt a great part 
of the evidence, on which the claim of descent from nobility 
or the relation to such, is based, in cases of systematized 
delusions of persecution (often directed against one person), 
it contains the strangest persecutions claimed to have been 
endured. In other cases the symptom reflects the incohe- 
rence of the contents of consciousness (disintegration of the 
individuality, see above), as in the case of Rother and very 
frequently also in the fanciful and peculiar narrations of 
paretics. On the whole an inner connection with the 
disorders of memory, which is to be presumed a priori, is 
also established by clinical experience, for the symptom 
belongs to the almost never failing phenomena of the three 
mental diseases characterized by. temporary occurrence of 
memory defects; hebephrenia, presbyophrenia and progres- 
sive paresis. 
No less remarkable is the negative modification of the 
falsifications of memories, the occurrence of circumscribed 
gaps in the otherwise well retained material of memory, 
without there being an indication, that a clouding of the 
sensorium or loss of the ability to attend could have existed 
at the time of the event in question. For the correct con- 
ception and description of this symptom the greatest value 
must be placed on these preliminary conditions. No one 
will wonder, if a patient with the initial symptoms of 
typhoid or meningitis has completely lost the remembrance 
of hours and days, for instance of a journey from Rome to 
Berlin while in this condition. Just as little do we wonder 
tKraepelin: Ueber Erinnerungsfalschungen, Arch,}. Psych., Bd. 17, p. 830. 
*See page 13. 16 
Outline of Psychiatry in Clinical Lectures. 
at the complete loss of remembrance in the post-epileptic 
state, of the fanciful events of delirium tremens, other toxic 
deliriums, hysterical delirium, a state of profound inebriation 
or finally of normal trauma. Also for those events of a 
mental disease, in which at the same time a loss of the 
ability to attend could be established, the complete extinc- 
tion of memory thus seems comprehensible. But it is 
entirely different with the symptom of negative falsification 
of the memories. Here individual actions and occurrences, 
which have happened apparently in perfect mental clearness, 
are effaced from the memory, while events closely related 
in point of time are accurately remembered. But there are 
two circumstances, which do not seem to be wanting as 
characteristic signs of the symptom and might serve to pave 
the way for its explanation; the occurrence concerned as to 
the action seems always to happen at the time of intense 
emotion, and besides it is connected with a definite quanti- 
valent idea, and so that it either appears as their result 
and so induced or would serve for their invalidation and 
refutation. The most typical examples have occurred for 
me in the so-called querulant insanity and related states of 
chronic partial psychoses. To illustrate what has been 
said, 1 could cite the case of a master tradesman, living 
here, committed, but still busy with his work, who has been 
proven to have insulted a policeman publicly on the street 
by indecent words and gestures and afterwards swore he 
did not do it. This man under the influence of a quantiv- 
alent idea, which for a time decided his whole conduct, held 
the officer to be his personal enemy and spy, for shortly 
before he had been injured according to this idea, and 
without doubt at the time of the offense he acted under the 
influence of an intense emotion. But just as little could a 
doubt exist from the exact knowledge of the person and 
the whole affair, that the respectable and religious man was 
wholly averse to committing a conscious perjury, while he 
had actually sworn falsely. Of etiological factors merely a 
marked family tendency to mental disease was to be dis- 
covered in the man of middle age. C. Wernicke. 
17 
The last three symptoms mentioned are connected in 
so far with the subsequent correction of the contents of 
consciousness as they evidently represent the excess of 
such a correction, and its morbid excess, while the process 
of correction in itself could be regarded as normal. All 
three symptoms evidently belong to each other, and their 
mutual relation may be expressed, that we subordinate the 
first to the qualitative falsification of memories, the other 
two to the quantitative. Instead of the expression positive 
and negative we might perhaps rather designate the two 
atter as additive and substractive, so lhat we would now 
have the uniform nomenclature to distinguish three forms of 
falsification of memories, a qualitative, an additive and a 
substractive. 
If we will now undertake to make an explanation, it 
will be best to treat all four symptoms collectively. Next 
in regard to subsequent correction it would soon occur to 
you how closely related this symptom is to that of the 
explanatory delusion so long familiar. Only the subsequent 
correction perhaps corresponds more to the refined psycho- 
logical* requirement, while the explanatory delusion to a 
cruder mechanism. The explanatory delusions are generally 
obtruded on the consciousness by unconscious process of 
deduction and therefore with such elementary force, while 
the subsequent correction occurs slowly, it is a conscious, 
actual mental operation, which reaches its conclusion after 
long deliberation, that the patient becomes clear over a 
number of things, which had prevously seemed incompre- 
hensible. The patient Bohm, whom you remember, was in 
such a process of clarification and stated, he could not 
decide at the time which of the various assumptions was 
correct. 
But it shows that the slowness and profoundness of 
this subsequent correction must lead to an irreparable falsi- 
fication of the mental possession, so that the disappearance 
of the elementary symptoms, e. g., the phonemes, which 
called for the explanatory delusion, the confusion, which has 
been once caused, cannot be repaired. Explanatory delusion 18 
Outline of Psychiatry in Clinical Lectures. 
and subsequent correction are the two fundamentals of this 
so-called systematization, and therefore it is not strange, if 
you find the proposition universally accepted, that systema- 
tization is equivalent to incurability. Still the proposition 
in this generality is not correct, and surely not for the 
majority of those systems in acute mental diseases, which 
usually depend so largely on explanatory delusions. As we 
shall see later, there is on the contrary one of the most 
curable mental diseases, in which temporary systematization 
is the rule, the acute hallucinosis, and the same seems to 
be true in the simple acute psychosis of fear. 
While for the chronic psychoses the proposition might 
have unlimited application. But how much more favorable 
in these are the conditions for subsequent correction in 
morbid senses! In the acute diseases mentioned there are 
weeks and months in which an accession of morbid compo- 
nents stream into the consciousness in such abundance, that 
one displaces the other. The elementary symptoms are 
afterwards silenced, and what has remained of them, no 
longer have the power to correct the former mental posses- 
sion, but rather succumbs to the united force of the again 
normally functionating process of identification and the 
previously acquired ideas. While in chronic cases the new 
acquisition bears very much the stamp of the normal event, 
so that the old possession should behave toward it differ- 
ently than to the new normal acquisitions. 
As we have seen above, the processes of irritation, 
which are at the base of the elementary symptoms of the 
chronic psychoses, may all be regarded as a consequence of 
sejunction; we will therefore have to consider the explana- 
tory delusion and subsequent correction in the paranoiac 
states as unavoidable, if also merely direct consequences of 
sejunctive processes. Whereas the symptom of the delusion 
of retrospective relativity may be credited and indirect con- 
nection with the sejunction. We have seen that we must 
trace the delusions of relativity chiefly to a process of 
irritation being manifested in secondary identification. If 
we have once accepted this view, then there is nothing C. Wernicke. 
19 
against the further assumption that the same quantity of 
irritation which is associated in the acts of perception with 
the peripheral excitation of a projection field, may also cause 
the excitation of memorial images by the way of association 
and thus delude the relation of their own person. But the 
accession in the quantity of irritation so required may be 
due, as we have seen, to the arrest of nerve energy in 
consequence of sejunction. 
That the positive or additive form of the falsification of 
memories has to presume a prior dissolution of association, 
needs no further discussion. The stability and reliability 
of our memories depend in great part on the collegation 
strictly accomplished between them in point of time, and so 
we may say that the memories are so closely united by 
the threads of time that foreign elements find no place 
between them. This association in point of time then must 
be broken through, if the pseudo-events of confabulation 
shall be held to be true. This only is the possibility for 
the occurrence of the symptom explained, therefore the real 
mechanism of origin still remains obscure. But the mode of 
origin and occurrence of the symptom need to be discussed. 
The first assumption that it is a matter of memories of 
the pseudo-events in an acute mental disease, is evidently 
untenable, for all those confabulations which occur without 
a preceding acute stage of the disease, and these we here 
have in min’d and might exclude the others from the concept 
of confabulation. But from whence must these events 
clearly described in all detail, which have never been 
experienced, and for anyone versed in the matter the 
assumption seems wholly excluded,that it is a question of vol- 
untary productions, intentional deceptions or lies in ordinary 
parlance. The confabulations are not lies, because the 
patient is fully convinced of their truth. As the contents 
of this confabulation very often have a fanciful stamp, similar 
to the events of the dream, I regard it very possible that 
they are real memories from dreams. 
The following might be cited in favor of this possibility. 
It is occasionally found that the sane person on awaking Outline of Psychiatry in Clinical Lectures. 
20 
from a dream believes for a short time the occurrences 
during the dream. But that only occurs when the contents 
of the dream are not too contradictory to the laws of real- 
ity, and when they are readily joined to the last events in 
points of time. The latter condition would be fulfilled, e. g., 
when in consequence of a mild intoxication the remembrance 
of the last events of the previous evening is lost or can 
only be vaguely recalled. The insane patient may be 
wholly deprived of both these corrections. The continuity 
of his memories in point of time is neither so stable, that 
foreign terms could not be inserted, nor are the laws of 
reality so inviolable for him as for the sane person. It is 
evidently the fact of sejunction, which removes the hin- 
drances to the reception of dream events into the store of 
memories. But perhaps something else may be necessary 
to lead to the occurrence of confabulation, e. g., an abnor- 
mal vividness of the dream events. However it would take 
too long for us to go further into the conditions, which are 
certainly not inaccessible. 
For the negative or subtractive form of the falsification 
of memories there is a common analogue in the post- 
hypnotic phenomena. Commands may be given a person 
hypnotized, which he later performs while awake, without 
remembering the command. For our consideration the 
performance of the command is unessential and merely an 
indication that the consciousness was affected at the time 
the order was given. Whereas essential for us is the 
complete absence of memories of the command, while on 
the other hand the action surely Cannot be regarded as 
really voluntary. As we are compelled to trace this effect 
of suggestion to the fact that foreign components are 
implanted in the organ of consciousness, without their 
entering into association with its other contents, a circum- 
stance which also may seem comprehensible grossly 
mechanical for the cogent influence of these transplanted 
components of a foreign consciousness on motility—so we 
will have to admit for the gaps in memory in this symptom 
the absence of associative collegations for the explanation C. Wernicke. 
21 
of the circumstance, that real occurrences may not be 
remembered. Still the close relations which these gaps in 
memory with respect to contents show to the quantivalent 
idea, intimate that the associative collegation is not entirely 
absent, but is only a very biased idea and limited to the 
quantivalent, otherwise the occurrence of the apparently 
conscious acts would not be explicable. It is then prob- 
ably the matter of a limitation of consciousness, as it is 
known only from states of intense affect. As the actions, 
which occur during the lapses of memory, often seem due to 
affects, a factor favorable to subsequent forgetfulness may 
be perceived. But this factor cannot be exclusively utilized, 
for otherwise it is inexplicable why only certain kinds of 
the insane present this symptom. 
XV. 
REVIEW OF THE ELEMENTARY SYMPTOMS PREVIOUSLY 
DISCUSSED. THE QUANT1VALENT IDEA. 
A review of the elementary symptoms occurring in the 
paranoiac states permits us to make the following distinc- 
tions. We found changes in the contents of consciousness, 
i. e.} delusive ideas and erroneous opinions, with unimpaired 
action of the consciousness, in so far as it is expressed in 
formerly retained logic, attention' and ability to attend, and 
finally with the ability of adjustment to surroundings. But 
the intact possession of the abilities does not prevent the 
specially dormant contents of consciousness from seeming 
to fall to pieces in a certain measure, a fact which we 
indicated as sejunction, i. e., disjointing of the several com- 
ponents. These components were firmly united structures, 
namely complete experiences, but the sejunction is shown 
by the fact that the most contradictory of these memories 
could coexist. The sejunction hypothesis then leads us to 
the better understanding of certain symptoms of irritation 22 
Outline of Psychiatry in Clinical Lectures. 
and thus to symptoms of deranged action of the conscious- 
ness, next of the autochthonic ideas and imperative 
conceptions* then of hallucinations and the delusion of 
relativity. The explanatory delusions which occupied so 
much of our discussion, could, as normal manifestations of 
the action of consciousness, be confronted by the direct 
psychotic symptoms previously mentioned. As very closely 
related to the explanatory delusion we have become 
acquainted with the subsequent correction of the contents 
of consciousness, the most essential condition for the so- 
called systematization, and so found a process which is to 
be attributed to the reactive manifestations of normal action 
of consciousness toward false intrusions, while we again 
might perceive psychotic symptoms in the different kinds of 
falsification of memories, which in themselves morbid, yet 
seem to have definite, conformable relations to the existing 
derangements of the contents of consciousness., mostly in 
such a manner that the range * of their occurrence seems 
dependent on the extent of the change as to contents. In 
the train of these psychotic symptoms three different modes 
of origin would have to be differentiated at least, for they 
appear in part as reaction of a well retained action of con- 
sciousness to the change in the contents of consciousness: 
these include the explanatory delusion and subsequent 
correction ; in part as direct consequences of sejunction; the 
contradictory contents of consciousness of many old cases, 
the additive and subtractive form of the falsification of 
memories; finally as processes of irritation, which are 
dependent on sejunction; the hallucinations, the delusion of 
relativity and retrospective relativity, finally the autoch- 
thonic ideas. 
*Imperative conceptions are very rarely an essential element of the paronoiac states 
if the cases of inveterate, habitual control of the actions by imperative conceptions are 
attributed to the limnal states of mental derangement, where they belong in my opinion. 
Therefore I do not disclaim that between the autochthonic ideas, quantivalent ideas and 
imperative conceptions transitions exist, in which it is difficult to give the symptom its cor- 
rect position, But in general the three symptoms may be readily differentiated. When 
Friedmann: Ueberden Wahn, Wiesboden 1894, recently in his ingenious paper attributed 
the imperative conceptions to quantivalent ideas and denoted the latter as the chief element 
in the formation of the delusion, he pays me too much honor and leaves the basis of clinical 
experience. C. Wernicke. 
23 
The quantivalent ideas, which might be repeatedly 
mentioned, are naturally attached to the last group men- 
tioned, they are apparently closely related to the. imperative 
conceptions and autochthonic ideas, and it is a question, 
whether they can be.separated from these symptoms, and 
whether a sharp boundary line is possible. The quantiva- 
lent ideas are sharply separated from the autochthonic by 
the fact that they are in no way judged by the patients 
as foreign intrusions in the consciousness; on the contrary, 
the patients perceive in them the expression of their most 
personal nature, and in the struggle for them very truly 
carry on a conflict for their own personality. Nevertheless 
they are often felt to be annoying and the patients 
frequently complain that they can think of nothing else. 
But they must ever remain far separated from the impera- 
tive conceptions, because they are regarded as normal and 
justified, completely explained by the mode of origin, while 
the imperative conceptions are recognized as unwarranted 
and often as directly absurd. 
If therefore clinically the differentiation of the symptom 
from the two others related to it is readily accomplished, its 
mode of origin is still unexplained. In this respect it is to 
be remarked, that in general we may define the quantiva- 
lent ideas as memories of some especially emotional event 
or a whole series of such connected events. Thus for 
instance were the following occurrences, which lead to the 
origin of quantivalent ideas; the discovery of a man who, 
has undertaken the administration of an estate and had 
shared as an heir, that he had been essentially wronged in 
the division; the report of the suicide of a dear friend, the 
death of the husband, the perception of an old maid that a 
gentleman pays her attentions, the observation of a wife, 
that her husband takes a great deal of snuff in spite of her 
opposition; finally, one of the most common cases, the con- 
demnation or decision of superiors, which is felt to be 
unjust. The emotion thus arising therefore bears a very 
different stamp and may either be designated more as anger 
or vexation, more as sorrow or disgust or sexual excitement.. 24 
Outline of Psychiatry in Clinical Lectures. 
At any rate you infer from this enumeration, that almost 
every event may lead to the origin of a quantivalent idea, 
that it does not at all depend on the kind of emotion, and 
there must be quantivalent ideas which belong wholly to 
the norm, but nevertheless the individual’s mode of action 
may be so designed that it has a morbid stamp. Who, 
after the loss of his property, after condemnation to 
disgraceful punishment, after the death of a dear friend, 
takes his own life, surely acts under the influence of a 
quantivalent idea, and we will have to designate the mode 
of action as abnormal, although it is not to be traced to a 
mental disease. It may then have to be ascertained in any 
individual case whether a morbid quantivalent idea or one 
within the domains of health exists. You will be inclined 
to rest the decision of this question on the fact, whether 
the motive is sufficient or not for the dominating emotion 
inherent in the remembrance. But this criterion fails us 
completely, as the example of the querulant proves; a part 
of these patients had actually been wrongfully condemned 
and had every reason to revolt. More reliable is the crite- 
rion, that in the cases with morbid quantivalent idea, this 
symptom is not alone, but a series of other psychotic 
symptoms is soon added. So especially is the delusion of 
circumscribed relativity characteristic of these cases.* 
The following is a typical example of morbid quan- 
tivalent idea. A gentleman 61 years of age, who was 
recently presented to you, gives as the reason for his 
admission “the annoyances,” to which he has been sub- 
jected outside of the asylum. In the asylum he is entirely 
free from them and feels so well that he has been here 
four years and expects to remain. Several attempts to 
discharge him have been a failure, because the same 
annoyances have led to the intervention of the police and 
his return. Originally it was a certain man, only known to 
him by name, who resided in the vicinity and whom he 
therefore met frequently on the street. He noticed how 
*See page 10. C. Wernicke. 
25 
this gentleman stopped and waited for him, but acted as 
though he counted the windows of a house. He therefore 
went to the other side of the street, but the next time 
observed how this gentleman spoke to an acquaintance at 
the same place and about him, as he is convinced, 
although he could not hear it. He consequently passed close 
to the two gentlemen and said: “Perhaps you want some- 
thing of me?” He then went to his residence and noticed 
that the gentlemen followed him and stopped before his 
house. Arrived at his residence, he went to a window, 
flourished his cane and exclaimed: “Come in here, I will 
be at your service.” A similar meeting another time 
resulted that the gentlemen actually followed him home, 
ascertained his name and made a complaint to the police. 
That was the circumstance that led to the patient’s first 
admission. 1 presented him in the clinic then, ascertained 
that the patient’s delusion of relativity was exclusively 
directed against the person of one of these gentlemen, a 
contractor, and then asked the patient: “But why should 
this gentleman annoy you?” The answer was extremely 
characteristic. He could only think of the following. He 
knows the brother of this gentleman very well, who, like 
himself, had been a regular customer of a wine merchant 
six years ago. The patient for a year had been interested 
in the merchant’s daughter and proposed to her, but broke 
off the engagement because he learned that her father was 
in a poor financial condition. The contractor had probably 
said to the other gentleman: “There goes the rascal who 
jilted the girl.” The most careful examination and obser- 
vation of the patient did not reveal any psychotic symptoms, 
other than that he claimed his perceptions were correct. 
He was therefore discharged at his request after a few 
weeks, but was soon readmitted and this happened a 
second time. Since then he will not try it again. The 
annoyances to which the patient was subjected outside, 
were both times far more numerous than before, other per- 
sons and the police had taken part, but it was all traced 
back to the one contractor, who in the meantime had told 26 
Outline of Psychiatry in Clinical Lectures. 
the old story to others and instigated the police to watch 
him for insanity. In the asylum never an indication of a 
delusion of relativity or other signs of a mental disease has 
been observed in the patient. 
In this typical case of circumscribed autopsychosis we 
see the quantivalent idea combined with a wholly circum- 
scribed, but later broadened delusion of relativity, which in 
the asylum where the patient only meets strangers, is never 
manifested. The basis of the quantivalent idea is the 
contrast, which the not perfectly honorable mode of action 
described forms with the patient’s otherwise . upright char- 
acter. It is to be assumed that the patient at the time of 
the first meeting described was thinking of his former 
experience and felt it to be a stain on him. A glance that 
he caught, the waiting attitude of the man who could know 
about the matter, then led to the permanent association 
with the temporary dominating train of thought, not falsi- 
fied as to its contents, but as to its value, a very similar 
act to falsified secondary identification, as was at the 
foundation of the delusional formation in the young assailant 
previously described.* As you recollect, exactly the same 
happens in the delusions of physiological relativity, as it is 
so aptly described in Raskolniknow. But it is not an acci- 
dent, that Dostojewski’s hero is previously depicted as a 
person morbidly nervous and of the weakest, most sympa- 
thetic spirit; under these circumstances, the remembrance of 
the murder perpetrated must remain an unassimiliable novum 
in the consciousness, so to speak, and so we found in all 
cases of delusion of autopsychical relativity the difficulty of 
association with the old contents of consciousness to be the 
basis of the quantivalent idea. 
To follow the indications of the preceding case we will 
reach the proposition, that such events especially will lead 
to the origin of a quantivalent idea, which from their con- 
tents are very hard to assimilate,/, e., to be made consistent 
with the present contents. As such events may happen, to 
the soundest mind, we will have to demand special conditions, 
*On page 10. C. Wernicke. 
27 
by which the quantivalence is shown to be of a morbid 
character. Normally there are remonstrances, which gradu- 
ally lead to a correction of the quantivalence. In morbid 
quantivalence these remonstrances prove to be inaccessible, 
and likewise the clinical sign of the delusion of relativity 
occurs, corresponding wholly to the hypothesis of irritation 
previously found joined' to the sejunction process. 
If we will pursue the clinical signs farther, it will be 
proven that the perniciousness, which is due to this symp- 
tom, is well known and must be sought in the extremely 
intense emotion, which accompanied a certain event. As such 
a known cause is not to be ascertained for other psychotic 
symptoms, this serves to characterize the morbid quantiva- 
lent idea. 
As in the case described, so also in a series of similar 
cases, a stable, tolerably permanent disease type is shown, 
which gains its partiality from the traditional name of fixed 
idea. Still in the most of the cases explanatory delusions 
are added which may ever increase in extent. Subsequent 
correction of the contents of consciousness and the different 
forms of the falsification of memories may also be added, 
and thus a firm delusional system arises, whose complex 
contents do not at all correspond to. the relatively simple 
and often very insignificant causes of origin and is apt to 
conceal and mask them. In old cases it is easy to ascer- 
tain these delusional structures, but we are often limited to 
conjecture with respect to the real fundamental quantivalent 
idea and the events from which it started. It is compre- 
hensible that recovery is out of the question in all cases of 
this kind, as in all other cases of extensive systematization. 
While if the extent of the diseases is limited to the first 
psychotic elements, recovery is possible by the gradual 
occurrence of vigorous remonstrances. Two cases, in which 
recovery has occurred were typical types of the so-called 
querulous insanity.* The clinical presentation of such 
*One of them was refused restoration to citizenship by the experts, because querulous 
insanity is known to be incurable! Yet the patient’s conduct showed that he had actually 
recovered. 28 
Outline of Psychiatry in Clinical Lectures. 
patients had often proven beneficial as well as the commit- 
ment in itself, the consciousness of being considered insane 
and permanently under guardianship, are vigorous and 
helpful remonstrances. The recovery is always very 
gradual by the avoidance of the causes for revival of the 
affect, the affect gradually disappears. 
It would take too long for me to cite here all the 
details of the quantivalent idea, nevertheless I would not be 
able to be exhaustive, for naturally there must be, according 
to contents, almost infinite varieties of this well character- 
ized form of chronic autopsychosis. For practical reasons I 
will only permit myself to hint that the possibility of 
acquiring an accident annuity may readily become a quan- 
tivalent idea. Finally I will not omit stating that like 
almost every other psychotic symptom, the quantivalent 
idea may form the initial stage of a progressive acute or 
subacute psychosis including progressive paresis, and that 
it is a symptom rarely absent in melancholia. 
In concluding this discourse, I will report a case pro- 
gressing to systematization. A maiden lady about forty 
years old, teacher of physics in a young ladies’ seminary, 
very capable, zealous and greatly interested in her work, 
believed to observe that one of her unmarried male asso- 
ciates, with whom she had been on friendly terms for years, 
had earnest intentions with respect to her. She noticed 
that he often stood by a window while teaching, where he 
could look into her class-room, that at recess he frequently 
stood in the corridor, through which she must pass with 
her scholars to her class, that he saluted her very defer- 
entially. This perception which she found confirmed by 
various accidental meetings, caused her great emotion, she 
spent hours and nights in inward struggle as to how she 
should act, and especially how to behave the most incon- 
spicuously, so that the scholars and her associates did not 
notice it. As she believed she was no longer a master of 
her feelings, she tried to avoid these meetings, and even 
went so far as to intentionally cut him. About this time, C. Wernicke. 
29 
she observed that her pupils seemed to know of it, remarks 
were noticed, which related to the matter, perhaps sporadic 
phonemes also"occurred, for she heard: “How troubled he 
looks.” Associates, who formerly had been rather distant, 
now visited her oftener and very frequently spoke of the 
young man, while her real friends withdrew and appeared 
to disapprove of her “affair.” Even the director interfered, 
in that during the recess he talked to the teacher and kept 
him at another place, farther from her, than he generally 
occupied. After some time this teacher left the school to 
study abroad. On his farewell visit he was extremely 
confused, changed color, and particularly a long look 
betrayed to her, that he well knew how she felt and 
reciprocated her affection. After he had gone, she observed 
that part of her associates were scornful and malicious 
toward her, a part sympathetic and considerate, at any rate 
their relations were generally known and any mention of 
this teacher contained allusions to them. The director must 
have made the matter the subject of a discussion in 
the conference; she could perceive it from the manner of all 
those present when she came in. All these events took two 
years. Direct reports did not come to her from the teacher, 
and she began to doubt if he was an honorable man. She 
must admit that her behavior toward him had been reserved, 
but she still believed he should have declared himself, like 
an honorable man. Completely engrossed in the sacrifice 
she had made by her conduct for the sake of the discipline 
of the school, she once had a passionate scene with the 
director, whose rude meddling she had not forgotten, and 
was given a six months’ leave of absence, with the advice 
to go to a sanitarium. The superintendent of the institution 
to which she went, found delusions of grandeur and perse- 
cution and pronounced her incurably insane. When 1 saw 
the patient three years after the beginning of her illness, 
she was the guest of friends and occupied herself in teach- 
ing the children. Neither in her manner nor in her talk 
was there anything peculiar, so the report that she had 
been pronounced incurably insane by the superintendent of 30 
Outline of Psychiatry in Clinical Lectures. 
the institution, must of course excite surprise, therefore the 
patient Was led to1 seek my advice. I found her an educa- 
fed refined lady, who was also perfectly clear, that she had 
the right to arrange her relations to the young man accord- 
ing to1 her own discretion, but tier sense of duty to the 
school had left her no choice, “she had sacrificed her right 
to her duty.” She had no doubt of the young man having: 
intended to propose. Still she must aJmit that he had 
never said a word that could' not be interpreted indifferently, 
if he had not declared himself, what she considered not 
quite fair on his part, this was principally due to the- 
intrigues anct rude interference of the directors and teachers. 
She did not believe my assurances, that all her fancied, 
perceptions were to be explained by a morbid biased opinion 
and depended on delusions, yet she was induced to go to a 
sanitarium voluntarily, where she remained however only a 
few weeks, 1 now learn two years later, that the patient, 
has resumed her calling in a private school and is perfectly 
capable, but in the meantime she has fallen out completely 
with all her relatives and blames them in part that she 
has been robbed of her life's happiness. Explanatory 
delusions and falsification of memories may have been the 
components of her now completed system. 
I cannot help adding a brief remark. If instead of a 
delicate and educated lady it had been a matter of a some- 
what indiscreet person, she would certainly have energetic- 
ally asserted her claims to the teacher and been a typical 
example of the persecuted persecutor, so much talked of 
recently.* In my opinion the most of the cases are to be 
traced to some morbid quantivalent idea, only that this 
peculiar basis of the system often remained hidden to the 
biased observers.! Also the superintendent, whose opinion 
had produced the lady’s not wholly unjustified indignation, 
*Magnan, Psychiatric Vorlesungen, German by Mobius Leipzig, 1891. 
tin these cases the prejudices relate to the partiality of the disease claimed by me and 
often misunderstood. As to the sense in which I comprehend this partiality is very evident 
by this representation, so that I may well refrain from a detailed refutation of the attacks 
recently directed against me by Hitzig: Ueber den Quarlantenwahnsinn. Leipzig, 1895, C. Wernicke. 
31 
•only saw the surface of the matter and has no presentiment 
of the real nature of the disease. 
A psychopathic foundation, from which the quantivalent 
idea might have arisen, does not exist in the lady. But it 
will not be wrong to consider her “critical’'’ age, combined 
with an excess of mental efforts and the thus induced 
improper mode of life, to be ample ground for the occurrence 
of a sexually colored quantivalent idea.. 
WHEN IS A MENTAL DISEASE TERMINATED? 
XVh 
The question whether and when a psychosis, which has 
•not recovered, is to be considered terminated, is, after all 
that we know at present, one of the hardest that can be 
asked, and still in like manner of theoretical as well as of 
practical significance. Theoretically its importance is evident 
from the fact, that in the autopsy of terminated cases, 
we will expect to find only the residues of morbid 
•changes in the organ of association,* no longer the changes 
themselves. Practically the real terminated cases could 
be compared to recoveries with defect in other pathological 
provinces. Nothing stands in the way of the discharge of 
certain cases from the asylum, as soon as the change in 
the contents of consciousness is of a harmless nature, as e, 
g., is so often met with in the fancied inventors and found- 
ers of new views of life. The points, which we have for 
the judgment of this question, are of course to be sought 
exclusively in the province of symptomatology. Our task 
then consists in examining the psychotic symptoms we 
have become acquainted with from the point of view, 
whether and in how far they are the expression of a 
disease process still active. 
Of greater importance owing to their paramount signif- 
*/. e., proliferations of neuroglia. Of epochal importance in this respect seems to me 
the work of C. Weigert: Beitrage zur Kenntniss der menschlichen Neuroglia, Frankfort of 
M. 1895. We may hope that a pathological anatomy of the psychoses will be erected 
by him. Outline of Psychiatry in Clinical Lectures. 
icance in almost all paranoiac states, will this be especially 
true of the explanatory delusions. These often actually 
represent an endless series, in that one may always be 
produced by the other, and so the process of delusion form- 
ation goes on indefinitely. While in other cases we see 
the same change as to contents continue and an explanatory 
delusion follow only by intimation. An obvious difference 
is certainly to be maintained in this diverse mode of 
reaction; only the question is, whether it is due to real 
pathological conditions. 1 have above intimated, that an 
energetic reaction to the once instituted change in the 
contents of consciousness is to be considered in itself a 
normal action, and that then the explanatory delusion as 
well as the intrinsically related process of subsequent 
correction of the contents of consciousness, may not depend 
on pathological processes. This subsequent correction 
always presumes that the alteration of consciousness, as to 
contents, remains of dominating interest to the patient. 
The simplest example, which is here offered is the 
delusion of a patient failing to appreciate his disease, that 
at the time of his illness he has been wrongfully impris- 
oned and robbed of his freedom. We may assume, that such 
a patient in resuming regular work and returning to settled 
conditions meets with so many other normal interests, that 
he must have an especially unfortunate temperament if his 
chief interest continues engaged with his fancied wrong. 
But if we assume a jurist, impregnated with the idea of 
justice could have met with this fate: then the dominant 
interest devoted to the wrong done him and thus the 
acquirement of new explanatory delusions, would be com- 
prehensible. He will make charges and institute claims for 
damages. But “what happens to the one, happens to the 
others,” then nothing is more evident than the thought 
that the same injustice has happened to others also. If he 
is now dismissed with his complaints, he perhaps believes 
that it is not only due himself, but also his fellow-sufferers, 
that he press his claim further. The repeated adverse 
decree shatters his faith in the administration of justice, he C. Wernicke. 
33 
comes to the suspicion that the judges are bribed, perhaps 
by those who originally had an interest in putting him in 
the insane asylum, or that justice is warped to hush up 
the probable blunder on the part of the asylum. This 
special experience is also generalized. All legal processes 
he now considers from this point of view and so constantly 
forms false opinions. He may make the readily possible 
assumption, that the wife has caused the commitment to 
the asylum. In the asylum he fancies she has taken up 
with another, who has fought and crushed him for the time 
being. But now outside of the asylum, the suspicion again 
arises, he begins to watch all his wife’s movements from 
this point of view, notices things he had never considered 
before, gives expressions a false interpretation, etc. If, in 
consequence of this, the affects normally to be expected 
occur, morbid jealousy arises, the insane jealousy, with all 
the conflicts, which finally terminate in the patient’s 
recommitment. In all these affairs and calamities he will 
misjudge according to his biased point of view his relations 
to other persons and the regulations of society, whether 
they uphold him or the opposite side. So we see a whole 
chain of false opinions formed, pure delusions, each suc- 
ceeding link the logical sequence of the preceding, and any 
station of the whole road may be the starting point of 
quarrels, affronts and violence. In fact there is no account- 
ing for the actions of these uncured insane. 
We will now investigate what the conditions are, which 
in spite of the mental disease being really passed, induce 
such an incurable termination. That the real individuality 
plays a great role, has already been hinted at. Also the 
importance of a suitable occupation 1 have emphasized, for 
it may divert the patient’s interest largely into normal paths. 
But of still greater significance will be the surroundings 
and social medium, in which the patient is thrown. If he 
is associated with imprudent people, who believe his false 
conception of the past and confirm him in it, if he becomes 
engrossed in the equally imprudent newspaper accounts of 
his companions in fate, he is again excited and will 34 
Outline of Psychiatry in Clinical Lectures. 
scarcely escape a renewed formation of delusions, while 
every day, every week, which elapses after his discharge, 
without the patient asserting his fancied claims and think- 
ing of them, is a great gain for him and favors the fading 
of this range of interests false as to contents. So an 
affective conative state must be regarded as the most com- 
mon preliminary condition of the explanatory delusion. The 
patients gradually and in favorable cases observe, that the 
revival of the time of their illness acts on them unfavorably, 
and I can show you many patients of the kind now actively 
engaged and self-sustaining, who speak of their illness very 
reluctantly, and this puts many obstacles in the way of a 
medical examination. From this consideration it practically 
follows, that we cannot be too circumspect in the discharge 
of improved insane, while on the other hand, as a means 
of strengthening the patients’ normal interests by an inde- 
pendent, busy life and thus afford the possibility of further 
restitution later, it cannot be withheld. Again unfortunately 
it will often be unavoidable, that the patients are discharged 
without entering into regular work and settled social rela- 
tions; under these conditions then, which are not only 
pernicious by the absence of normal interests, but must 
even dispose to the origin of depressing effects. The 
dominating interests may then continue to be engaged in 
the injustice suffered, an affective state occur and 
the further formation of delusions is not lacking. So 
we see individual relations may decide the termination, 
another evidence of the correctness of our view, that the 
formation of explanatory delusions may not depend on 
an existing disease process. A further evidence lies in the 
fact, that in certain acute diseases the absence of explana- 
tory delusions is characteristic and accompanied by a pro- 
nounced defect, an apparent negation of intellectual action. 
In these cases the formation of delusions does not occur, 
because the normal elaboration of the changes in contents 
by the mechanism of association is lacking. 
Wholly different than with the explanatory delusions is 
it with the majority of the other symptoms familiar to you. C. Wernicke. 
35 
Here as the chief means of systematization are to be con- 
sidered the additive and subtractive falsification of the 
memories and the delusion of retrospective relativity. They 
seem then only to make their appearance, as has been 
shown, when the extremely firm structure of association is 
loosened by sejunctive processes. But also in the presence 
of this preliminary condition, the same symptoms may be 
absent, without a real state of defect affording the explana- 
tion, so we are still led to the assumption, that these 
symptions so essential for the construction of a delusion 
system must have another basis of origin. The next 
assumption is, that not the past sejunction, but that still 
present, then the disease process still active, is essential. 
At least this view is the most probable for the three other 
symptoms: the autochthonic ideas, hallucinations and delu- 
sions of relativity, of course with a certain qualification. 
I then remind you that in residuary hallucinosis, we 
have made the acquaintance of a stage of disease, which 
with the attending delusion of relativity of its time, we 
have essentially considered as a sequence of terminated 
sejunctive processes. The representation is perhaps to be 
modified somewhat in the fact that it corresponds to a 
stage of decline, of the remission of the sejunctive processes 
to a stage then, in which the most acute sejunctive 
processes and thus all other severe symptoms of an acute 
psychosis have disappeared, on account of which the afore- 
said elementary symptoms may stand preeminent in their 
whole clearness. It was assumed above, that a habit could 
occur for the excitation by regurgitation of the nerve current, 
and thus these symptoms become habitual, while the 
pathological process might cease. Evidently this assumption 
would only apply to those cases, in which phonemes and 
delusions of relativity had existed very long, also at the 
time of the acute stage of the disease, and for such cases 
the possibility will have to be admitted, that in a certain 
measure they are perpetuated as purely function derange- 
ments. Without mentioning this consideration, it will 
always be justified at least to perceive in these symptoms 36 
Outline of Psychiatry in Clinical Lectures. 
the signs of a still existing disease process, if under certain 
circumstances comprehended in the decline. 
The occurrence of the delusion of circumscribed relativ- 
ity, as we have made its acquaintance on page 298, forms 
a second assumption. In the wholly stable condition, which 
these patients present, and from the appearance of delu- 
sions of relativity only in very definite situations or at the 
sight of certain persons, we will have to consider the 
delusions of relativity as something fixed, habitual, then 
merely as the result of a fundamental change. The reflec- 
tion is immediately forced upon us, that these delusions of 
relativity are nothing new as to contents, then do not 
really represent an elaboration of the delusion. And if we 
apply the same criterion to the habitual phonemes and the 
delusion of relativity in the aforesaid cases, we may be able 
to expect, that they are characteristic as to contents and in 
the way, that they may be regarded as the expression of 
existing delusion, but do not lead to their elaboration or 
association of new delusions. In fact there are cases of this 
kind, in which, in spite of the continuance of hallucinations 
and delusions of relativity, a real systematization will never 
occur. 
In the affect generally a sign will be possessed, whether 
the hallucinations and delusions of relativity run in habitual 
channels or contain a novum. The fading of the affect is 
therefore often of favorable significance, for it proclaims an 
abatement of the hallucinations and the delusions of rela- 
tivity and then their gradual cessation. An inner connection 
between the affect and the occurrence of these active 
psychotic symptoms cannot be mistaken; for affects, which 
according to their mode of origin must be designated as 
normal, often form evidently the exciting cause for the 
sporadic occurrence of phonemes annd delusions of relativity 
in otherwise wholly stable states. We have made the 
acquaintance of an example in the rare case of the occurrence 
of sporadic phonemes in querulants. That is the reason 
why patients with sejunctive processes of only limited 
extent are often doomed to live in the asylum after their C. Wernicke. 
37 
relative recovery. Every attempt to take up the hard 
struggle for existence results in a return of the psychotic 
symptoms and only a well conducted asylum offers the 
patients constant consideration and kind treatment, but also 
the freedom from material want, which for these patients 
forms the preliminary condition of their permanent psychical 
equilibrium. 
The proposition may be advanced in general, that a fine 
gauge of the more or less robust constitution of a brain is 
to be found in its ability to resist affects of especially 
depressing sort. Apparently able men, who have never 
passed through a mental disease, are occasionally seen to 
shun with nervous timidity the occasions of intense affects, 
which are unavoidable in psychical elaboration of annoying 
occurrences. On the other hand nothing is more evident to 
me of the partiality of the derangement and the normal 
condition of the brain, contrary to the claimed degeneration, 
than the exalted disposition and enjoyment of contest, with 
which many querulants carry their struggle for right to the 
limit, in spite of all disappointments and adversities. 
As the chief guide, that the disease process has actually 
terminated, we next have to consider the experiment, 
whether the return to civil life is successful. Therefore this 
experiment should be made when possible, and it is the 
duty of the asylum to provide an active and freer life for 
those invalids who cannot live otherwise. A second test is 
equally important, but occasionally out of the question in 
some cases. It consists in the state of the general health. 
Its grossest expression is the maintenance of a relatively 
high weight. Derangements of sleep and appetite are thus 
excluded. The great influence exercised on nutrition by the 
brain, which is hardly credited by the laity, will be encoun- 
tered especially in the acute psychoses. But it is shown in 
the chronic psychoses and principally in the paranoiac 
states, that any acute excerbation and all morbid affective 
states are accompanied by loss of weight, which can only 
be explained by specific trophic influences and is often in 
striking contrast to the apparently unaltered balance between Outline of Psychiatry in Clinical Lectures. 
38 
imports and exports. Experiments in metabolism here offer 
a grateful task which would undoubtedly lead to interesting 
and instructive results. 
XVII. 
COURSE OF THE CHRONIC PSYCHOSES. ETIOLOGICAL 
CLASSIFICATION. GRIESINGER’S PRIMORDIAL DE- 
LIRIUM. 
The summary knowledge of the paranoiac states we 
have now acquired, does not of course complete the matter, 
for you have only become acquainted with certain dominant 
symptoms, while a large number of others, which may 
occur intercurrently, will first be met with in the acute 
psychoses. However you will be able to discover the chief 
traits of the great majority of paranoiac states, • and so 
satisfy the requirement, which, for instance, must be coin- 
cident with any psychiatric opinion, namely that the 
psychiatric symptoms, which constitute the mental 
derangement of a certain case, are to be accurately 
enumerated in detail, a requirement unfortunately not often 
complied with in the opinions of so-called authorities. 1 
cannot sufficiently impress the fact upon you, that you only 
have the right to declare a person insane when you can 
prove it by the establishment of certain psychotic symptoms: 
thus only will you be spared the humiliation of having your 
opinion subjected to justified criticism by the laity. The 
“general impression,” on which even well known repre- 
sentatives of our specialty occasionally depend, when unable 
to elicit definite psychotic symptoms, is a mere phrase and 
must rouse the greatest mistrust, if the diagnosis of a par- 
anoiac state is to be established. The sharpest rebuke is 
deserved when in cases of the kind, it is claimed it is a 
matter of a well-known and relatively simple morbid state, 
to which the name simple chronic paranoia is applicable. 
Judges, like laymen, may then readily gain the impression 
of intentional deception and so the standing of all alienists C. Wernicke. 
39 
is damaged. To avoid such blunders it must be considered, 
that the most evident egotism is far from being a delusion 
of grandeur, while mistrust, suspicion and hatred of one or 
several persons is not a delusion of persecution, or that the 
paranoiac states are mental derangements relatively easy of 
demonstration by very definite psychotic symptoms. 
In some of our most familiar text books you find par- 
anoia divided into simple, chronic and hallucinatory. How far, 
or rather how little, such a distinction is justified may be 
inferred from my descriptions. An independent significance 
does not fall to the lot of hallucination, at least of the 
almost ever dominating phonemes. 
A certain apology is perhaps required, for my having 
chosen the term paranoiac states to designate all chronic 
mental derangements with marked change in the contents of 
consciousness. It might at least be desirable that I attempt 
to clearly outline the seemingly well known simple chronic 
paranoia. 1 purposely refrain from such an attempt, for, in 
my opinion, there is no well known disease of the sort, if 
the name is not monopolized for a very small number of 
cases. 1 will soon take these up again.* 
With respect to these paranoiac states, the defectiveness 
of our knowledge is especially manifest, when we attempt 
to classify them according to their development and subse- 
queht course. Only certain borderland cases are well known 
to us. 1 will briefly recapitulate them according to the data 
1 have so often alluded to. Among the residuary mental 
derangements there are a certain number, which we have 
become acquainted with as stable conditions, generally 
characterized by slight dissemination of the symptoms and 
integrity of the other functions. Then there are a number 
of cases far better known, characterized by a very gradual, 
insidious development and equally slow uniform course, in 
which true acute paroxysms or marked excerbations never 
occur. For both types of disease, as for all changes as to 
contents, a disease curve may be constructed which corre- 
sponds to the extent of the disease state. The form of the 
*See page 40. 40 
Outline of Psychiatry in Clinical Lectures. 
curve in the first would run parallel to the axis of the 
absciss, in the second rise uniformly and slowly from the 
axis of the absciss. 
A few remarks are to be devoted to these latter states 
of extremely chronic course. They correspond to the some- 
what common type of delusions of persecution of slow origin, 
to which after a long time a consecutive delusion of 
grandeur may be added. The period of slow and imper- 
ceptible development of these cases, owing to which it is 
often very hard to determine the exact time they begin, is 
characterized by the occurrence of delusions of relativity and 
then sporadic phonemes of like purport. A quantivalent idea 
may be the first symptom to appear and determine the trend 
of the delusion of relativity. Phonemes gradually become 
prevalent, and hallucinations of other senses and abnormal 
sensations are associated. The delusion of persecution is 
then systematized in two ways. First by explanatory delu- 
sions, which are related to the fact of the hallucinations: 
the so-called delusion of physical persecution; then by those, 
which refer to the author and motive of the persecution. 
The delusion of grandeur is usually attached to the last 
series of explanatory delusions, owing to the logical neces- 
sity of explaining the display of such large force, the 
demand for so many men. With well retained self-posses- 
sion and formal.action of thought, technical expressions of 
more or less peculiar sort are finally formed, often first 
arising as phonemes, which induce the patients to coin 
words. These patients’ mode of expression thus becomes 
extremely characteristic. Owing to their well functionating 
logical apparatus, the whole conception of the world is 
gradually transformed, and, according to the individual’s 
mental possession, philosophical systems of more or less 
peculiar construction may be formulated. Formally correct 
logic and unmistakable mental fertility are retained to the 
last. In the philosophical literature of the last century a 
work of several volumes by a scholar, evidently insane, may 
have astonished you and led you to shake your head. The 
final result of the whole disease process is a change in the C. Wernicke. 
41 
contents of all three parts of consciousness, for the change 
in their own body sooner or later attracts the patient’s 
attention; were a name to be chosen for these cases, it 
would be a matter of a chronic total psychosis, in the later 
stages at least. But just as unquestionably the initial 
symptoms exclusively, and largely the whole first period of 
the disease is to be sought in the allopsychical part. The 
delusion of relativity, alone demonstrable for a long time, 
has the above described allopsychical character, the halluci- 
nations with the following explanatory delusions effect a 
gradual, but steady new interpretation of the world, and so 
for these first years of the disease the designation chronic 
progressive allopsychosis is proper or chronic hallucinosis. 
The epithet progressive amply implies, that the psychosis 
finally becomes total, as it involves the autopsychical part 
from the time of the delusion of grandeur. It further seems 
to be characteristic of these cases, that serious motor 
symptoms never occur. If relatively frequent* still the 
absolute number of these cases of purely chronic progressive 
course is small. It is these, which most correspond to 
seemingly so frequent and common chronic paranoia. The 
two female patients Schmidt and Reising are examples, the 
latter also had a quantivalent idea from the first. 
A third kind of course of the paranoiac states has 
become familiar to me by a number of cases. It develops 
in the special way, that it represents a continuation of an 
attack of acute psychosis, after several attacks of the same 
have occurred in former years and terminated in complete 
recovery. 1 have observed this course to follow acute hal- 
lucinosis or acute hallucinatory allopsychosis, and generally 
in alcoholics. The progression of the chronic state, which 
as to contents always occurs as a delusion of physical per- 
secution seems to be far more rapid and deleterious, than 
that of the preceding chronic form. 
A fourth kind of course of the paranoiac states 1 can 
only speak of here in anticipation. In the acute psychoses 
we will become acquainted with the depressive state of 
♦See Alienist and Neurologist, vol. xx, p. 564. 42 
Outline of Psychiatry in Clinical Lectures. 
melancholia, an acute general disease, which is characterized 
by the complex affect and the general akinesis intrapsy- 
chically conditioned. Such a melancholic state may simulate 
a true melancholia for a long time, until the altered conduct 
of the patient shows that the intrapsychical derangement of 
function abates and simultaneously delusions of relativity and 
corresponding phonemes have made their appearance. It is 
usually an outbreak of anger, which causes the patient to talk, 
and now in an instant a picture wholly changed is revealed. 
The paranoiac state, now evident, is usually equally composed 
of delusions of persecution and grandeur, outbreaks of violent 
cursing and tendency to deeds of violence accompany it in 
almost characteristic manner, and a falsification of the 
contents of consciousness, even to their confusion, occurs 
quite quickly. The patients seem to be able to tarry for a 
long time in this stage of confusion as to contents, with 
lowered energy in their actions, but without real dementia. 
1 am not clear as to the final termination. Not to be mis- 
construed, 1 will remark, that the confusion as to contents 
does not occur in this kind of course alone, but represents 
the sequel of any extensive falsification of consciousness. 
The patients finally use a train of concepts, which are 
peculiar to them individually, so that they become incom- 
prehensible to other individuals and other individuals are 
misunderstood. The confusion as to contents is' only 
apparent and would not be noticed by another individual 
with exactly the same falsification of the consciousness. 
Undoubtedly it will be possible later to determine a 
series of well characterized types of course among the 
paranoiac states, other than the four mentioned, but at 
present 1 must be satisfied with these allusions and limit 
myself to the problem here awaiting us. It will consist in 
ascertaining the laws governing the several psychotic 
symptoms and the changes as to contents; the combination 
of the symptoms cannot be mere accident, any more than 
that in general nervous diseases definite, well characterized 
groupings of the symptoms are so common. In the latter 
the reason is evident, owing to the definite arrangement of C. Wernicke. 
43 
the nerve tracts in definite areas. If I now remind you, 
that in a certain sense we might consider the changes in 
the contents of consciousness as focal symptoms, we may 
apply this consideration to them and regard certain groups 
of symptoms as the expression of definite anatomical 
arrangements in the association tracts. At present, as 
stated, we are only on the threshold of our knowledge, and 
I ought to warn you especially of regarding the types of 
course above outlined as the ones particularly frequent. In 
fact they form only a fraction of the many varieties of 
unknown kind, which are contained in the very numerous 
paranoiac states. 
It may perhaps seem strange to you, that in the task 
of arranging the protean paranoiac states, I seem to disre- 
gard the etiological principle of classification. If 1 really 
did, 1 would be on the wrong track; but you will observe 
that 1 have expressly mentioned the etiology of alcoholism 
in the psychoses beginning in paroxysms and of progressive 
course and with the delusion of physical persecution. In 
fact the question of etiology forms the second equally 
important problem to be solved. But it would be amiss to 
talk about lead palsy ere its most common type, bilateral 
radial paralysis, had become familiar, so also would it be 
wrong to base the classification of the psychoses wholly on 
their etiology. Its bias can be shown by the fact, that the 
acute hallucinosis of the dipsomaniac also occurs in those 
who do not drink. We now hold that the psychoses are 
brain disease, and may presume that one and the same 
focus always produces the same symptoms. A province 
accessible of investigation is thus offered. Still we cannot 
expect from definite causative agents, that they will always 
be manifested at the same focus, any more than that a 
cerebral hemorrhage is always located at the same place in 
the brain. The etiological factor therefore will always have 
to be secondary in the question under consideration. At 
the same time 1 am well aware that, under certain circum- 
stances, the locality affected may be ascertained by the 
etiology, of which the lead palsy above referred to, as also 44 
Outline of Psychiatry in Clinical Lectures. 
the disease of the posterior columns from alcoholism and 
syphilis, finally the most common type of progressive pare- 
sis are examples. In the acute hallucinosis of the 
dipsomaniac, in hebephrenia and presbyophrenia we will 
later become acquainted with psychoses, in which it is very 
similar. But in general it cannot be too strongly empha- 
sized, that our best principle of classification must be that 
of the anatomical arrangement, in other words, that of the 
natural grouping and sequence of the changes with respect 
to contents. 
At present 1 must be satisfied to define my standpoint 
in these important questions, but reserve the privilege of 
returning to them more fully later, for the acute psychoses 
unconditionally demands a definite attitude toward these 
questions. But a brief mention of this point was not to be 
avoided; the chronic psychoses are largely the terminations 
of acute psychoses. But then in the face of certain state- 
ments of current literature it seems demanded of me not to 
simply keep silent as to these tendencies.* The writings 
of a prominent French psychiater, Magnan, have turned the 
vascillating public opinion in this direction in Germany. 
You would therefore readily get the impression, that a new, 
better name had been discovered for a number of generally 
known clinical facts, and there are really only two large 
groups of diseases to be differentiated in the province of 
chronic mental derangements; those of degenerates on one 
hand and a mental disease not etiologicaliy characteristic, 
but well pronounced clinically, which the French author 
terms “Delire chronique a evolution systematique,” or 
“Paranoia completa” by the German translator. As you 
see, 1 must contest such a classification on principle, for it 
practically amounts to the same thing as opposing to all 
the other mental diseases a form of chronic mental derange- 
ment, presumably well known clinically, and recognizing for 
the former only one etiology, that of so-called degeneration. 
*1 am greatly pleased to say that in my critical review of Magnan’s theory 1 encounter 
Hitzig. But still 1 believe 1 perceive a satisfactory agreement in the fundamental views he 
advances in his excellent book on querulous insanity, in s,ite of all his polemics against me. C. Wernicke. 
45 
In my opinion we are here confronted by the same extrav- 
agance as has frustrated every previous attempt to classify 
the psychoses. This standard type of an entirely chronic 
paranoia is carried much too far, as I think, and embraces 
a large number of psychoses differing from each other and 
yet to be differentiated. And only thus could the author have 
arrived at the idea of contrasting it with the whole large 
province of psychoses occurring in “degenerates.” With 
respect to these latter cases, I do not doubt that this etio- 
logical point of view will prove just as useful as many 
others; but it has been greatly over-rated by Magnan, yet 
I believe you will be able to learn one fact from it: that 
psychotic symptoms are prone to occur in “degenerates,” 
which remain isolated, like the quantivalent idea, or only 
attain a slight degree of intensity, so that it must still be 
questionable whether such an individual is to be considered 
really insane. That such borderland cases are very often 
met with in “degenerates” is nowhere demonstrated by 
such evidence as in Magnan’s studies; but it is an exag- 
geration if the author seems to think that cases, like those 
I have termed circumscribed autopsychosis or quantivalent 
idea, occur only in “degenerates.” That is wholly out of 
the question, unless the presence of the psychosis itself is 
to be accepted as an evidence of the degeneration. 
In concluding this discussion, permit me still one remark 
for the purpose of preventing possible misconceptions. I 
am well aware that I have very unsatisfactorily performed 
the task I outlined for myself in giving a faithful descrip- 
tion of the paranoiac states. You will find later that I 
have wholly omitted a number of important symptoms, 
while on the other hand 1 have mentioned many that 
really belong to the acute mental diseases. 'But the diffi- 
culty here lies in the affair itself. It is really impossible 
to clearly describe one province alone, as I have attempted, 
without encroaching on the whole domain and giving it 
some attention. But this impossibility has proven to be 
very much greater in the acute mental diseases, so that 
after many years’ work I must finally change entirely the 46 
Outline of Psychiatry in Clinical Lectures. 
plan of my labor and discuss the acute mental diseases, 
which are the chief source of the paranoiac states, after 
these. And this also applies to the individual symptoms. 
Every new symptom appearing spontaneously may give a 
mental disease an acute character. The majority of the 
chronic mental diseases are distinguished by acute par- 
oxysms of new symptoms, which occur at some period of 
their course. I have intentionally avoided as much as 
possible a description of these states, because they will 
form a special chapter in speaking of the acute psychoses; 
but it was impossible to separate these paroxysms from 
individual symptoms appearing for the first time, for, as 
universal in Nature, there are imperceptible transitions. 
The history of psychiatry is a topic of extreme interest 
to the expert, but for you, who yet need to be instructed 
in its rudiments, it must be subordinated to the urgent 
requirements of the present. Nevertheless 1 must not omit 
mentioning one point, whose importance in the history of 
our science is beyond question. It is the matter of Gries- 
inger’s primordial delirium. As you will hear so much of 
this great clinician, it will not seem strange that his text 
book is still one of those most read and has wrought a 
marvelous effect in its time. In this book Griesinger takes 
a standpoint alone and one not shared by well known 
older authors, in that he contests the occurrence of primary 
changes in the contents of consciousness without prior 
melancholic depression, and in 1867* he was converted to a 
more correct conception in the statement of his “Primordial 
delirium,” after Snellt had taken the lead in his paper on 
“Monomania as a primary form of Mental Derangement.” 
Owing to the dominating position, which is inherent to 
Griesinger’s personality, you can fancy that the theory of 
primordial delirium now proclaimed by him agitated all 
minds and was greeted as a great advancement in our 
science. 1 very clearly remember at the time of beginning 
♦First published in 1870 in his “Vortrag zur Eroffnung der psychiatrische Klik, in 
Arch.f. Psych., I. 
fAllg. Zeitsch.f. Psych., Bd. 22, 1865. C. Wernicke. 
47 
my psychiatric career in 1871, that this point was ever 
uppermost in the discussion of psychiatric topics. At any 
rate it was one of the undesigned effects of the book and 
Griesinger’s teaching, that this only rarely happened, for 
the interest of all young psychiaters was largely devoted 
to brain and nerve diseases. In this state of affairs you 
will be surprised that I have not spoken of “primordia 
delirium” among the psychotic symptoms, which are to be 
considered the basis of the paranoiac states. This 1 will 
immediately explain. But first permit a remark as to Snell’s 
situation, to whom priority to Griesinger undoubtedly 
belongs. Why is not Snell’s name instead of Griesinger’s 
united with the famous conception of primordial delirium? 
The answer is very simple; while the same phenomenon is 
discussed by both authors,.the versatile clinician, skilled in 
clinical methods only had occasion to reduce it to a definite, 
elementary psychotic symptom, which he called primordial 
delirium. Both authors proceed from the same clinical 
experience, that in a certain kind of insane, whom Gries- 
inger calls primary paranoiacs, Snell monomaniacs, delusions 
of persecution appear in exalted, self-conscious disposition, 
without preceding melancholia,* hence apparently primary. 
But while Snell was satisfied to grossly outline the course 
of these cases, the integrity of the intellect, the frequent 
complication of consecutive delusions of grandeur, Griesinger 
tried to penetrate deeper into the nature of the affair and 
find the source of the delusions of persecution and grandeur 
in primary false ideas, or more definitely, false judgments. 
To make my meaning clear, I cite some of these judgments. 
In a patient (a case of a psychosis of fear, e. g.,) the 
thought arises that his parents, his wife, and children are 
dead, and he is at once convinced of it. The thought 
comes to another, that he will be executed, to a third, that 
he is a millionaire or of noble descent. It is a matter of 
these “spontaneous thoughts,” which are held to be true, 
a phenomenon reminding you of imperative conceptions and 
autochthonic ideas. 
*In the conception of the older authors, 48 
Outline of Psychiatry in Clinical Lectures. 
Thus at least can I now understand Griesinger and so 
1 perceive his real merit. We see, how he expresses him- 
self in this respect from his address at the opening of the 
Psychiatric Clinic on May 4th, 1867.* “According to our 
present assumption the processes, which result in ideas, 
occur in the ganglion cells of the gray cerebral cortex. 
As abnormal gait results from the spinal disease of tabes 
dorsalis, so by abnormal action of these cortical cells, 
images, words, ideas, which do not correspond to the reality, 
must be immediately produced.” We see that Griesinger 
takes a standpoint very similar to our own. Still the diffi- 
culty has not escaped him, that irrational judgments might 
be produced from the preformed material organs of the 
process of thought. To explain this he points to two 
series of phenomena. First the derangement of the ganglion 
cells may be purely functional and excited from other remote 
places. He names this phenomenon, in which the first 
excitement may be due, e. g., to sensations in the intes- 
tines, concurrent ideas. We may at once accept this view 
and, as you remember, 1 have repeatedly alluded to such an 
origin of definite ideas under the term of ideas of fear. The 
place to discuss this fully will be with the acute psychoses. 
The second series of clinical phenomena, which he 
perceives to be analogous to the primary occurrence of 
certain false judgments in the insane, is the occurrence of 
imperative conceptions in neurasthenics and the great fre- 
quency of zoanthropy in delirium potatorum, finally the 
subjective sensation of a well-defined color, red, in certain 
pathological (e. g., epileptic) brain states. Here a connection 
with the regular false judgments of the insane is only to 
be established with respect to imperative conceptions. So 
then Griesinger did not understand how the conformibility 
of these contents, delusions of grandeur and persecution, 
occurs, which perhaps “in five out often patients form the 
chief purport of the delirium during the whole course of 
the disease.” We now know, thanks to Meynert, that 
*Arch.f. Psych., 1 p. 143, C. Wernicke. 
49 
there are attributes of the primary ego, of the child and 
primitive man, which are reflected in this conformity, and I 
only need refer you to his essay “Ueber den Wahn”* to 
make it perfectly clear. Man in the primitive state will 
interpret as actions those events effecting his weal and woe 
as actions; on this basis delusions of persecution and gran- 
deur are developed as the two fundamental forms of the 
individual’s reaction, like that of men to the impressions of 
the world. 
But we will now have to ask: Is there actually such 
a primary origin of the delusions of persecution and gran- 
deur, as Griesinger thinks? This question I can only 
affirm conditionally. According to my information the pre- 
sumably primary delusion of persecution for the chronic 
psychoses is generally developed either from delusions of 
relativity, as above described, or as an explanatory delusion, 
and any mode of origin, in my opinion, is out of the ques- 
tion for the paranoiac states, if we will not include the 
delusion of persecution of dementia. The same is true of 
the delusion of grandeur.t Still I admit, that besides the 
consecutive delusion of grandeur, which is developed as the 
logical sequence of the delusion of persecution, besides the 
delusion of grandeur of dements, which will be spoken of 
later, there are still two sources of the so-called delusion of 
grandeur, which may be readily overlooked and then the 
occurrence of a primary delusion of grandeur might be sim- 
ulated. The one is a somatopsychical change in the 
contents, a hypochondriacal feeling of well-being localized 
in the chest, like the feeling of fear, and alternating with 
t. It is usually related to the process of respiration and 
described as particularly easy respiration. Thus it was for 
instance in the patient Schulz previously mentioned,+ who 
fancied he was filled with the Holy Ghost, addressed 
inspired sermons to the people and traveled to a neighbor: 
+ConsequentIy I believe I am in accord with Snell, who essentially contests the primary 
occurrence of delusions of grandeur. Die Ueberschiitzungsideen der Paranoia. Alls. 
Zeitseh.f. Psych., Bd. 46, p. 446. 
*Sammlung von popular-wissenchaftlichen Vortragen, 1892, p. 83. 
{Alienist and Neurologist, vol. xxi, p. 16. Outline of Psychiatry in Clinical Lectures. 
ing city to take holy orders from a bishop. The delusion 
of grandeur is then only a case of my so-called ideas of 
well-being and forms the counterpart of the feelings of fear 
already mentioned. The second source is again the 
delusion of relativity, often in combination with certain 
quantivalent ideas, another time with the above described 
hypochondriacal feeling of well-being. The autochthonic 
ideas arising in cases of the kind, falsification of memories 
and the delusion of retrospective relativity then serve for 
embodiment in facts, the completion of the scheme, which is 
supplied by the exalted disposition and the increased 
self-feeling. 
I should expressly mention one exception, so as not to 
do violence to the clinical facts. A chronic mental disease, 
developing early in life, Sander’s* “primary paranoia,” 
seems to occur, in which primordial delirium forms the 
original source of the grandiose ideas, according to Griesinger. 
Still pure cases of the kind are.only very exceptionally 
observed. A careful study of these cases almost alwaj's 
permits the delusion of grandeur being traced to one of the 
elementary psychotic symptoms already mentioned. Except 
that an early essential mental weakness is peculiar to the 
majority of these cases of so-called primary paranoia, for 
the so-called primary paranoia and hebephrenia, to be 
described later, have many similarities and can be distinctly 
differentiated only in certain extreme, indisputable cases. 
According to my experience the most of these cases, in 
which not one of the real psychotic elements above men- 
tioned is provable, belong to hebephrenia owing to their 
early pronounced mental weakness. 
I cannot conclude this historical excursion without 
mentioning an important literary production, in which Gries- 
inger’s primordial delirium has found an eloquent champion, 
but unfortunately one overshooting the mark. Friedmann 
in his book “Ueber den Wahn”f seeks the peculiar char- 
*For a special form of primary paranoia see Arch. f. Psych., I, p. 378. The remarks 
as to the grandiose delusion on pages 278 and 279 relate to examples of so-called primary 
paranoia. 
tWiesbaden, 1894. C. Wernicke 
51 
acter of the delusion—we say the falsifications of 
consciousness as to contents—in the paranoiac states in 
those false judgments manifested according to the type of 
the primordial delirium. The closely related imperative 
conceptions are therefore regarded as a fundamental symp- 
tom of “paranoia” accepted by him, but understood in a 
far different sense. We will see later that his assumption 
for the acute mental diseases is often true, but his attempt 
at generalization must be repudiated. In the chronic it is 
disproven by experience, and we will not go wrong if we 
charge this one-sided view of the careful investigator to 
his want of large experience with the insane. IF YOU ARE 
AN ADVANCED PHYSICIAN or 
PROGRESSIVE LAWYER, 
YOU CANNOT DO WITHOUT THE 
NEUR0L0QI5T. 
HE ablest men in Neurology and Legal Medicine subscribe and 
write for it. 
The morbid movements of the mind, brain and nervous 
system are mirrored in its pages by master minds in medicine. 
It constantly gains and seldom loses subscribers. 
ADDRESS H# L# HUGHES, M. D., 
MANAGER AND PUBLISHER, 
3857 Olive Street, 
$5.00 Per Annum. ST. LOUIS, MO. THE 
Alienist and Neurologist 
VOL. XXIII. 
ST. LOUIS, APRIL, 1902. 
No. 2. 
OUTLINES OF PSYCHIATRY IN CLINICAL 
LECTURES.* 
DR. C. WERNICKE, 
Definition of the acute psychoses with respect to the chronic—Presentation 
of a case of acute psychosis almost recovered—Conditions and color 
of the explanatory ideas—A few new sources for the forma- 
tion of delusions; from analogy, defective atten- 
tion, pathological formation of associations. 
LECTURE EIGHTEEN. 
Professor in Breslau.t 
THE acute psychoses are primarily characterized by their 
mode of origin; we will have to regard all those mental 
disorders acute, in accordance with the use of the term in 
other diseases, which develop symptoms of significant inten- 
sity within a few hours or days. Besides it is to be stipulated 
as to the further development of the disease whether and 
how long it retains the acute character, or whether it re- 
covers or passes into a chronic state. In the latter instance 
the acute psychosis becomes the acute initial stage of a 
chronic psychosis. With the same right, acute stages of 
the chronic psychoses occurring in other than the initial pe- 
riod will have to be included among the acute psychoses. 
♦Continued from the Alienist and Neurologist, Vol. XXI, No. 2. 
tEnglish by Dr. W. Alfred McCorn. f » " l "» L T~ . - 2 
C. Wernicke. 
Still it would little accord with the complex actual con- 
ditions and the use of words based thereon, if we would 
regard the length of course alone as the decisive indication 
in designating a psychosis acute or chronic. Rather the 
quality of the disease type, the “acute character,” which 
adheres to it, owing to a rapid development, an indication of 
such independence, that even on longer duration of the dis- 
ease, or, where the condition of a rapid development does 
not exist, it will decide in favor of an acute psychosis. 
This shows the special position, that diseases of the nervous 
system must be given: a sciatica or other neuralgia of 
years standing, an old tabes may be attended by the most 
intense lacerating pains, the extremely chronic trouble of 
brain tumor is attended at well specified periods by the most 
acute brain symptoms, i. e. a combination of headache, 
vertigo, vomiting and general convulsions. Thus the acute 
reactions of the nervous system are seen to be very gen- 
erally dependent on irritation, which very often has no per- 
ceptible connection with the gross disease processes—the 
anatomical tissue changes. In our efforts to more definitely 
define the acute psychoses, we are consequently referred to 
other, more exhaustive criteria. I refer to my remarks* on 
the mutual relation of content and action of consciousness 
and then to the result, that the pathological changes in the 
content of consciousness must form the chief topic of our 
consideration, as they were in the chronic psychoses. We 
must now add, where this province is entrusted to 
us; the permanent or fixed changes in the content of con- 
sciousness. But we will not hesitate to further conclude, 
the pathological changes in the content of consciousness 
form the domain of the acute psychoses. 
If you will now cal! to mind the schemet I have given 
for the derivation of the symptoms, you will at once ob- 
serve, that it is also a scheme of the pathological changes 
in the action of consciousness, changes, which in their 
totality we have known as disorders of secondary identifi- 
cation. It would be the task of an independent theory of 
*See Alienist and Neurologist, Vol. XX, p. 548. 
tSee Alienist and Neurologist, Vol. XX, p. 153. Outlines of Psychiatry in Clinical Lectures. 
3 
symptoms of mental disease to discuss those derived from 
the scheme, to put their occurrence and significance in the 
different mental diseases in the proper light. Still any 
attempt of the kind would take us too far from our real 
task of becoming acquainted with actual causes of disease, so 
1 will confine myself to speaking somewhat fully of only 
the most important theoretically, of these disorders of iden- 
tification, which are indispensable to the general pathology 
of mental diseases. They are chiefly those symptoms, 
which come within the province of false sensations or in- 
timately connected with them. Besides I will have to 
confine myself each time in presenting patients to elucidat- 
ing the symptoms, that are new in their significance with 
respect to our scheme. 
Simple reflection will verify, that the symptomatology 
of the acute mental diseases cannot be exhausted by the 
symptoms derived from our scheme. Still we had seen that 
the action of consciousness produces the content of con- 
sciousness, so that a changed action of consciousness must 
of necessity result in changes in the content of conscious- 
ness, and we could define the acute mental disorders as the 
changes in the content of consciousness, we see effected 
within a certain time.J We are now often able to assume 
a priori, that these changes in the content of consciousness 
will be less fixed or of shorter duration in the acute men- 
tal diseases than in the chronic. Nevertheless the clinical 
significance of the disorders of the content of consciousness 
in the acute mental diseases is so essential and decisive 
for the fixation of a definite disease type, we feel that any 
theory of disease, which would neglect this point of view, 
must be biased and incomplete, insufficient for the great 
amount of clinical data. If in the chronic psychoses or 
paranoiac states we could confine ourselves in the main to 
the changes in the content of consciousness, you will now 
understand how much more complicated is our task in the 
acute psychoses, where the changes in the action of con- 
sciousness are equally as significant as those in content. 
So it is that the sequelae, which in the chronic psy- 
tSee Alienist and Neurologist, Vol. XX, p. 548. 4 
C. Wernicke. 
choses we say follow a number of elementary symptoms, 
are in great part manifested in the acute psychoses, even 
find there a broader application, e. g. the principle of ex- 
planatory delusions. And as explanatory delusions do not 
in themselves represent a pathological action of the organ 
of consciousness, we will become acquainted in the acute 
mental diseases with new sources of delusion formation, 
which are connected with normal mentality. The exper- 
iences we have had in this respect, form in a certain meas- 
ure a supplement to the theory of the paranoiac states and 
therefore most properly follow them here. A patient select- 
ed for discharge, who has been free from psychotic symp- 
toms for three months, offers a favorable opportunity. K. 
is a mechanical engineer of twenty-seven, with an aca- 
demic education, who is to be regarded as recovered from 
an attack (the second) of a severe complicated mental dis- 
ease, even to the defective insight for a few , of the 
symptoms at the time of the acute onset. His well retain- 
ed memory of the whole period of his illness amounting to 
about 1 Yi years, his intelligence and training in scien- 
tific observation render him peculiarly suited to afford in- 
formation as to certain symptoms. 
I will say merely that the patient fully describes the 
voices and autochthonic ideas at the time of his illness. 
We gather from this merely the lesson, that these elemen- 
tary symptoms of the paranoiac state generally occur also 
in the acute mental diseases. The explanatory ideas, the 
patient has added are more important for our actual pur- 
pose. He was always fully aware, that the voices, whose 
material embodiment he did not see, were not to be ex- 
plained physically, and so there was only left to him the 
assumption of supernatural action of “spirits,” as much as 
he at first resisted the evidence of his senses. He then 
explained the strange thoughts as inspired by these spirits; 
that it did not here result in a delusion of physical per- 
secution is certainly to be ascribed to the man’s scientific 
training. We also see from the example, that the explana- 
tory delusions are no less important in the acute mental dis- 
eases than in the chronic. A certain degree of retained Outlines of Psychiatry in Clinical Lectures. 
5 
intellectual power is necessary to the hypothesis: logical 
requisites and logical ability must be present for an expla- 
nation of the strange manifestations. In general this 
hypothesis corresponds to a certain degree with retained 
self-possession as it was usually present in our patients. 
Besides the content of the explanatory delusion is shown to 
depend on the patient’s individuality. How much this is 
the case can be seen from a second example. Among the 
thoughts inspired in him, our patient has also stated, that 
he has been in the world at different times as Wotan and 
Alfred the Great. He has therefore believed in transmi- 
gration. From my question if he had regarded it an act of 
resurrection, he developed the idea, that every person in 
his personality is to be looked upon as a definite arrange- 
ment of material part, and that he has considered it pos- 
sible for the same arrangement of molecules to be repeated 
at different times and so the same persons be produced. 
As much as he now laughs at the assumption, it must be 
admitted that only a person with a scientific mode of 
thought would be able to formulate such an explanatory 
idea. 
For the occurrence of complex explanatory ideas, as 
well as for the estimation of the autochthonic thoughts as 
such, a certain degree of self-possession must be inevitably 
presumed. If we accept that these false judgments, like 
those mentioned of having lived twice before at different 
times, could have been formed in this way, the smallest 
degree of retained power of judgment is necessary for such 
thoughts to be recognized as not originating according to 
the normal type. We will not then be astonished, if the 
acute insane, who lack self-possession, are sometimes in 
a state of complete confusion, strange ideas are obtruded 
and manifested, without their criticising them or attempting 
an explanation. In this way 1 recognize the occurrence of 
primordial delirium (Griesinger) in the acute insane, as 1 
have formerly* stated in speaking of Friedmann’s book on 
delusions. Although this author has adhered to his stand- 
*See Alienist and Neurologist, Vol. XXI, p. 315, 6 
C. Wernicke. 
point, carried much too far in my opinion in his new workt 
on the origin of delusions, and tried to base them on com- 
parative ethnology, it is still contradictory to the admitted 
exception of clinical experience. Besides you see at once, 
that the origin of imperative conceptions, or rather the cor- 
rect judgment, which the patients hold toward these ideas 
arising from pathological stimulation, is associated to the 
like preliminary condition of a certain degree of self-pos- 
session and power of judgment. We will observe in the 
future, that these gradations can be obliterated in acute 
insane by spontaneous thoughts and replaced by Griesing- 
er’s primordial delirium, because the stormy affects, which 
disturb coordinated thought, are relatively frequent in acute 
mental diseases. 
The patient describes a form of false sensation, which 
has not yet been met with and which he called a vision. 
He believed to have experienced whole scenes and situa- 
tions during his illness, which had in part happened at 
other times. Thus for example, he said he saw his father 
on the scaffold in a French marshal’s uniform, below the 
threatening multitude, heard the howl of the rabble and the 
executioner exclaim: “You must go.” To my questions 
the patient states that he then believed himself taken 
back to the time of the French Revolution and did not 
doubt the reality of the event, which he now calls a vision. 
We will later have to study this form of false sensations 
somewhat more closely under the designation of visionary 
hallucinations. The conclusion drawn from it is of interest 
to us here. He believed himself transferred to the other 
lands and other times and explained this by sorcery. But 
my objection, that he should not have believed in the 
reality of the experience, because his father had not lived 
at the time of the French Revolution, he confuted very re- 
markably. He stated to have then believed that his father 
and other persons, like the supervisor e. g. could have 
lived before at different times. We evidently have here 
a conclusion from analogy as the source of delusion forma- 
fWeiters zur Entstehung der Wahnideen und fiber die Grundlage des Urtheils. Mon- 
atsschr. /. Psych, u. Neurol, 2 Bd. 1. H. Outlines of Psychiatry in Clinical Lectures. 
7 
tion and the patient assures us, that he had reached this 
conclusion, because he had been firmly convinced of his 
prior existence. You remember the patient!, who claimed 
to have a double and generalized that everyone has one. 
You see that the insane make practical use of Goethe’s 
proposition: “What happened to one, happened to others,” 
a source of delusion formation of inestimable importance. 
But this delusion formation by conclusion of analogy will 
have to presuppose a relatively coordinated ability to think. 
We will see later that the combined hallucinations of 
several senses, of which you have just seen an example, 
are perferably associated to visionary conditions. In this 
case the clinical history has shown, that the patient often 
seemed to be completely abstracted and oblivious to what 
went on about him. Certain peculiar assertions made then, 
he now is able to explain in a satisfactory and instructive 
manner. The patient had once expressed his astonish- 
ment, that the supervisor could have disappeared through 
one door and at the same time come to another. Another 
time that his food stood before him without having been 
brought in, an occurrence which reminded him of the fabu- 
lous “table be set.” Both occurrences had seemed to him 
supernatural and marvelous. Now he says that it was an 
error in observation owing to faulty attention. He has 
often been so occupied, e. g. with false sight and hearing, 
that he has not sufficiently taken account of what went on 
about him. He has usually had his eyes closed, a state- 
ment I can confirm. We have here an instructive source 
of delusion formation, according to the principle of the 
effort to explain, in the diversion of attention by internal 
occurrences, and we see how very insignificant and ordinary 
events in this way appear to the patient in an incompre- 
hensible and mysterious light and according to individuality 
may lead to different explanatory delusions, here to the 
assumption of sorcery. We are able to assume that the 
mysterious, disorientating nature of these events is mani- 
fest in any case entirely irrespective of the fact whether 
tRother, See Alienist and Neurologist, VoI. XX, p. 552. 8 
C. Wernicke. 
explanatQry delusions follow or not, according to the degree 
of ability to think. 
As we continue our examination of patients we soon 
meet with a new, still unknown source of the formation of 
delusions. At a certain period of the disease the patient 
had called on his physician and later made the startling 
statement, that he considered him in a certain measure his 
son, also intimated that one of his fingers represented the 
person of the physician. We later learned that each of his 
fingers represented a certain person, one his father, one his 
mother, one Napoleon, while to the question what person 
a certain finger represented he was in doubt. The patient 
occasionally spoke of the legal position of the pater familias 
according to the Roman law, evidently based on this delu- 
sion. He now gives the following explanation: he got the 
idea that one of his fingers represented the person of the 
physician, because every time he saw him, even in visions 
and when he heard his voice a peculiar sensation occurred 
in this finger. It is the same with the other fingers. The 
patient is unable to describe the sensation more definitely, 
but states it was not a pain. We here see a new forma- 
tion of concepts in consequence of a pathological experience, 
simultaneous with, the occurrence of definitely localized 
pathological sensations, either real or pathological percep- 
tions of a definite content. We will term this process 
pathological new formation of associations and will find it 
very frequently in acute insane, if we are rarely able to 
obtain such a clear account of it. Besides the patient now 
definitely denies on being urgently questioned, that he has 
considered the one finger identical with the physician, he 
only meant that it has a definite relation to him. 
The example we have just become acquainted with 
will certainly recall well-known data. For instance the 
young man,* who became sexually excited every time he 
saw his father. 1 presented him as an example of 
somatopsychical delusion of relativity, but we cannot 
doubt, that a process of pathological new formation of 
associations is its basis. Other examples of this connec- 
*See Alienist and Neurologist, vol. XXI, p. 274. Outlines of Psychiatry in Clinical Lectures. 
9 
tion between somatopsychical delusion of relativity and 
pathological association are presented by our patients. 
Once during his illness he had begged that his bed should 
not be meddled with, because blood is thus drawn from his 
heart, for a long time he could not be touched, because it 
caused him discomfort, once declared his head would burst 
as soon as one of the attendants said a certain word. All 
this we may regard as an example of somatopsychical 
delusion of relativity. It is readily seen that this 
pathological association may exercise a decided in- 
fluence on the relation of the patient toward certain 
persons and chiefly his actions. Many wonderful, strange 
actions, wholly incomprehensible to normal thought, but 
also sometimes dangerous and unaccountable at any rate 
may be the result of this pathological new formation of 
associations. 
A favorable chance affords the opportunity of demon- 
strating ad oculo a similar state of diversion by internal 
processes as described by the patient C. It is a matter of 
a very complicated disease and likewise in a young 
mechanic. It is impossible to get a word out of him. He 
gazes about the auditorium abstractedly and does not seem 
to heed my questions. Once he turned to me, called me 
by name, showing that he is orientated as to his surround- 
ings, and at my request correctly repeated the Pythagoric 
theorum. He refused to demonstrate it, as it was too hard 
for him. Suddenly and wholly spontaneously he asserted in 
an animated tone: ‘‘You do not know Saxony and England.” 
But he can again be fixed further. He shows he is greatly 
occupied with a supposed abuse by the attendant already 
referred to, tells of it in detail, constantly returning to it. 
Here in Breslau everything is not effected by natural 
means. Voices had nominated him Mayor of Breslau. The 
voices came from the air and the most different directions. 
They are heavenly voices. He comes to this conclusion, 
because he sees nothing. Besides thoughts are inspired in 
him. He is Christ as well as a Jew, has existed once be- 
fore, confuting my doubt by the evidence of the third 
article of the Creed, which refers to the resurrection of 10 
C. Wernicke. 
the dead. Suddenly and entirely spontaneously he said very 
animatedly: “career.” 
You see he understands my questions and promptly 
responds, still it must be remarked that he occasionally 
looks abstracted and answers questions by the mere query: 
“What?” He apparently requires a constant exertion of 
action to external stimulus and otherwise seems to sink 
into a sort of dream with active false sensations. Never- 
theless he is wholly attentive in the meantime and shows 
he is able to correctly reproduce a number of four units ten 
minutes after it is given him. He promptly gives the date 
of his first acute illness five years ago, is aware of a sub- 
sequent relapse and considers it very possible that he is 
now sick again. We learn on inquiry that he has no head- 
ache, but very unpleasant feelings in the head, which he 
describes as boring and tearing, and are the result of the 
abuse by the attendant. If this is gone into more fully, he 
completes this statement: abuse by relatives committed at 
the same time. Suddenly with a glance at the attendant, 
who has accidentally gotten by from the chair: “I am not 
to blame.”* Claimed that this has been said of him. On 
leaving I tried to explain to him the purpose of the demon- 
tration. As he went out he replied: “But you also direct 
that which does something to me. Every officer has his 
honor, I am no common man.” 
In this patient we see an alteration of very different 
states of consciousness, first a diversion by mental pro- 
cesses, which render him almost inaccessible and at most 
reminds of the physiological state of so-called abstraction, 
then a momentary fixability and, in spite of many altera- 
tions in this condition, a well retained ability to attend. 
The state of abstraction reminds of delirious conditions and 
seems combined with a visionary clouding of consciousness. 
No more abrupt contrast is conceivable then in the atten- 
tive, perfectly clear consciousness immediately after. As 
internal stimuli, which are closely intermingled with his 
clear consciousness, we may establish abnormal sensations, 
autochthonic ideas, simple and disorientating phonemes. 
The disorientation chiefly affects the autopsychical, next the Outlines of Psychiatry in Clinical Lectures. 
11 
allopsychical domain. It is very possible that this patient 
will tell later, in case he should recover from this second 
relapse, of the mysterious occurrences during his illness and 
even be able to correctly explain them afterward by the 
diversion of attention, as the patient K. has done. 
Delusion formation by analogous conclusion, diversion 
of attention by events of the world, and pathological new 
formation of associations are quite often met with in the 
chronic psychoses. But with respect to the .other much 
more readily comprehended changes in content, already 
familiar to us, they are of subordinate importance. Differ- 
ently in the acute cases, where in subsequence of the 
manifold alterations in the disorders of content, at one time 
the former, again the latter dominates and by their in- 
fluence on the patient’s action demand consideration. 4 In 
this respect our patient’s report is instructive and must not 
be neglected. Understanding of the acute insane is far 
more difficult than that of the chronic cases. 
(To be continued.) Alienist 
THE 
Neurologist. 
AND 
ST. LOUIS, JULY, 1902. 
VOL. XXIII. 
No. 3. 
OUTLINES OF PSYCHIATRY IN CLINICAL 
LECTURES.* 
DR. C. WERNICKE, 
Professor in Breslau.t 
Definition of the acute psychoses with respect to the chronic—Presentation 
of a case of acute psychosis almost recovered—Conditions and color 
of the explanatory ideas—A few new sources for the form- 
ation of delusions; from analogy, defective atten- 
tion, pathological formation of associations. 
LECTURE NINETEEN. 
Lesson from hallucinations. Hallucinations of the different 
senses. Combined and visionary hallucinations. His- 
tory. Theory of hallucinations. 
The lesson from false sensations, which in our previous 
considerations could only be touched upon, forms the most 
important topic of a general pathology of mental diseases 
and must therefore be familiar to us in its fundamental 
traits, ere we can go on studying examples of the various 
types of the acute psychoses. Since the time of Esquirol 
the false sensations have been divided into the two large 
groups of hallucinations and illusions. The hallucinations 
are perceptions which occur in consequence of internal 
stimuli without excitation of the sense concerned by an 
external object, the illusions are false perceptions, miscon- 
ceptions of objects of perception actually present. Accord- 
ing to our scheme hallucinations belong to the group of 
♦Continued from Alienist and Neurologist, April, 1902. 
tEnglish translated by W. Alfred McCorn., a 2 
Outlines of Psychiatry in Clinical Lectures, 
psychosensory hyperesthesias,* i. e., they represent a 
pseudoidentification by pathological stimulus, the illusions 
are to be accounted to the psychosensory paresthesias,i.e., 
they signify a falsification of secondary identification. 
As to how far primary identification is concerned we 
will have to ascertain in speaking of the theory of false 
sensations. In the domain of the sense of hearing we have 
at command the cardinal data of hallucinations and from 
these we will proceed, as they possess by far the greatest 
clinical dignity. I again confine myself to those points, 
which are of fundamental significance in the matter of 
clinical experience. 
Hallucinations of hearing occur in two different forms, 
namely either as voices or phonemest, or perceptions of 
hearing of different kind. The latter, also called akoasmas, 
may be of the greatest variety, e. g., the patients hear 
crackling, crushing, clicking, stamping, knocking, thundering, 
drumming, shooting or chirping, hissing, boiling, dripping, 
howling, bellowing, neighing, roaring. These noises occur 
especially in very acute disease conditions, quite often with 
signs of a severe affection of the general condition. In the 
dry tongue and mouth an evidence will often be found, 
that the Eustachian tube and internal ear are often affected 
sympathetically, so that the origin of false sensations from 
subjective noises of peripheral origin in the ear cannot be 
excluded; especially is this true of the simple elementary 
noises. They would have to be placed in the group of 
hallucinations from intense peripheral irritation singled out 
by Kahlbaum, among the phenacisms, and hence among the 
disorders of primary identification. This sort of akoasmas 
are evidently very near to illusions, in that it does not 
prevent the peripheral mode of origin, that they are fantas- 
tically explained and utilized by the patients. This mode 
of origin tends to the experiences which every normal 
person has of occasional subjective noises in the ears from 
internal peripheral irritation. Pure tones may originate in 
this way. As akoasmas, which cannot be thus explained, 
*See Alienist and Neurologist, Vol. XX, p. 1S4. 
TSee Alienist and Neurologist, Vol. XXI, p. 267. C. Wernicke. 
3 
but must have another mode of origin, we will have to 
regard the hearing of distinct melodies, an orchestral selec- 
tion or other acoustic impressions of complex nature, like 
groaning, whining, children’s cries. 
The voices or phonemes are also two different forms, 
they are either expressly called voices, when they are felt 
by the patient to be something special, different from ordi- 
nary experience, or are ascribed to persons actually present 
or in the vicinity. The first case is a pure example, that 
patients create a special term for the designation of a 
pathological symptom. If such patients are asked if they 
hear voices they usually answer affirmatively without hesi- 
tation and with the appearance of fully understanding the 
question. Others make use of voices entirely of themselves 
and without external suggestion of the expression. This 
indicates that a very definite accent seems to adhere to the 
hallucinations of hearing in words. Usually the patients 
can definitely state whether these voices are of acquaint- 
ances or strangers, in the first instances they may give the 
names and differentiate voices of men, women and children. 
Also the designation angels’ voices, God’s voice is some- 
times due to an unusual, strange timbre. The voices at 
one time seem far away, again near by, they often come 
from the immediate vicinity, so that it seems to the patient 
as if whispered, spoken or shouted in the ear. The direc- 
tion from which the voices seem to come can usually be 
exactly stated and in this respect the patients often develop 
a very marked faculty of localization, manifest only during 
the disease. Not only the direction, but also the exact 
place and distance from which the voices seem to come,are 
stated, it quite often occurs that the voices seem to 
change their location independently. The patient is thus 
led to personify the voices, in that he complains they fly 
or hover about him, he looks for them under the pillow and 
hunts them like an annoying insect. At other times it is 
not the abnormally keen localization, but the very correct 
perception that the voices accompany the patient, e. g., on 
a change of residence or on a walk, which leads him to 
conclude that the voices can change location also. 4 
Outlines of Psychiatry in Clinical Lectures. 
In case of unilateral hallucinations, which are not rare, 
the voices change in direction with the position of the 
patient, a condition which under certain circumstances may 
lead to insight into the symptom’s subjective nature. In 
such cases it is usually possible to demonstrate either 
marked deafness or blunted keenness of hearing in one ear. 
In these cases the hallucination is heard at one time in the 
sound ear, again in the one diseased. Perhaps conformity 
to law in this respect will be shown, when the ear trouble 
is definitely located by a thorough examination. Our pa- 
tient K., who is hard of hearing from an old catarrh of the 
right middle ear, tells of a voice which has been so loud 
and close to the ear, that it had begun to bleed and in fact 
a small hemorrhage was once found in the external meatus. 
The voices, which are construed as emanating from 
persons present and projected to them, owe this attribute 
to the pathologically fine localization of the phonemes. 
This sort of voices, by which the patients are led to a false 
conception of the persons about, deserve the designation of 
disorientating phonemes. Practically they are of special 
importance, for they often turn the patient’s anger, rage 
and hatred to certain persons and may be the cause of 
violence. An assault on the supervisor by the patient K 
may be explained in this way. The disorientating pho- 
nemes are then the worst form of manifestation of voices, 
and in fact it is quite often observed that the first form of 
voices pass into the second, while the patient’s whole con- 
dition is simultaneously aggravated. The same observation 
may be made in inverse order. 
Hallucinations forcibly monopolize the patient's atten- 
tion, even when the false perception is not understood. So 
for example indefinite noises precede the distinct phonemes, 
and they generally disappear by the patient no longer 
hearing them distinctly, but only in whispers. In both 
cases the patients very definitely state that they must 
listen to the noise, although they do not understand its 
meaning. This is so in the patient K last presented. Like 
many other patients he regards this compulsion as a physical 
annoyance and a sort of abuse. C. Wernicke. 
5 
A second attribute of hallucinations is their incorrigi- 
bility. It has long been known, that the best reasons and 
intactness of all the other senses do not suffice to convince 
patients of the subjective character of hallucinations. The 
chief argument on which patients rely is quite often heard 
actually expressed: “I have seen it with my own eyes or 
heard it with my own ears.” And in fact the evidence of 
the senses is generally accepted unconditionally, when the 
whole attention is engrossed with the sense impression. 
But this is always the case in hallucinations, as we have 
just heard and also from our patients. The fact of the 
narrowness of consciousness, which was mentioned in my 
eighth lecture, prevents any correction at the moment of 
the hallucination, only after the disappearance of the hallu- 
cination could correction become effectual, then always when 
too late. The most intellectual patients, having to choose 
whether they will trust the evidences of their senses or 
not, prefer strange explanatory efforts than to admit the 
subjective character of the hallucination. The phonemes 
are not usually continuous, but cease at times when from 
proper advice a doubt as to the objectiveness of the voices 
may appear. They sometimes occur only paroxysmally. 
At the height of such attacks the attending symptom of 
anxiety very regularly occurs, but also quite often during its 
whole duration. Numerous constant hallucinations without 
any intervals are observed only in the severest per*acute 
cases of mental disease, when disorientation is simultane- 
ously present. Nevertheless it can usually be observed 
that a certain diversion of the patient by medical consola- 
tion, an examination, etc., is possible and the hallucinations 
at this time abate or disappear entirely. Solitude, silence 
and the exclusion of active sensory impressions generally 
favor the occurrence of hallucinations. But cases are now 
and then observed in which these conditions cause the hal- 
lucinations to disappear, while they are excited by external 
sensory stimuli (functional hallucinations, Kahlbaum). 
By reflex hallucinations Kahlbaum understands those 
which are produced by an actual sensation or another false 
perception, either in the same or another sense. Thus 6 
Outlines of Psychiatry in Clinical Lectures. 
Kahlbaum’s patient heard the derisive name “Uncle August” 
every time he first saw strangers. A patient of mine in 
the premonitory stage of delirium tremens with intense 
anxiety heard the words, “scamp” and “hang yourself” in 
the ticking of the clock and the bubbling of a fountain. It 
is well to regard it a reflex hallucination, when a patient, 
who for a long time has been very abstracted, later gives 
as its reason that 1 had ordinarily insulted him at the con- 
clusion of a conversation. It is perhaps due to reflex 
hallucinations that a few patients hear the contradictory 
commands—eat and do not eat, every time they see food. 
In their uncertainty only the decisive order of the physician 
will determine their action and get them to eat. 
After hallucinations of hearing, those of taste and 
smell are to be considered, owing to their great clinical 
importance. They occur most frequently in the form that 
the patients believe they taste and smell poison, when 
apparently the word poison is employed for the designation 
of the most diverse substances unknown to the patient. 
More definite names are not lacking; chloroform, phosphor- 
ous, sulphurous acid gas are smelled, things causing 
disgust, like dog and human flesh, manure, feces or urine 
are tasted. Hallucinations of smell of themselves alone are 
often of very long duration and continuous, especially the 
odor of putrefaction or of other disgusting kind, which is 
ascribed to pathological processes in their own body. Hal- 
lucinations of taste are usually the cause of refusal of 
food. They are often of course not to be separated from 
the tactile hallucinations of the tongue, which generally 
refer to foreign substances in the food. The examples cited 
show that the content of hallucinations is usually disagree- 
able, menacing. Accordingly the great importance of the 
symptom consists in the patients wholly or partially refus- 
ing food in consequence of their perceptions. Hallucinations 
of taste and smell are the most important and frequent 
causes of refusal of food. An especially bad prognostic 
significance is generally to be ascribed to hallucinations of 
taste and smell. Still this applies only to chronic mental 
diseases. In the acute and particularly in the peracute C. Wernicke. 
7 
forms hallucinations of taste and smell permit no special 
conclusion with respect to the prognosis. 
Paretics in the later stages are a well known exception 
to the general rule, that the content of hallucinations is 
largely unpleasant. These patients generally revel in per- 
fumes and they are often seen chewing, tasting and 
smacking their lips for hours and days, even with all the 
signs of pleasure, often without refusal of food having pre- 
ceded. Also in certain ecstatic states of the hysterical 
insane and after many acute intoxications such reveling in 
pleasing hallucinations of this sort occurs. 
In all cases of severe acute mental disease a dryness 
of the mouth and nose, which must afford the most favor- 
able basis for the origin of illusions, generally appears in 
consequence of the intense effect and thus induced motor 
restlessness. Evidently these false sensations of taste and 
smell are still less to be separated and differentiated from 
real hallucinations than in the other senses. 
Hallucinations of sight have in general the peculiarity 
that they do not of themselves have the stamp of tangible 
reality, but appear to be superficial pictures without depth. 
They are very often designated pictures by the patients, at 
other times apparitions, shadows or ghosts, an expression 
which points to definite explanatory ideas. Also the com- 
mon expression, “some trick is played on me,” permits 
the conclusion that hallucinations of sight are devoid of the 
semblance of reality. An exception to this most frequent 
condition occurs in those cases, where the sensorium is 
clouded, stupor, a dazed condition or an ecstatic state 
exists, as well as in somnolency. So it quite often happens 
that the same patients, who see “pictures” only in the 
day time, tell of nocturnal visions of physical tangibility. 
States of intense affect render visions of this sort possible. 
A dreamy state of consciousness may serve as the basis of 
the visions in alcoholic delirium, but in part they have also 
the stamp of reality, as other acute intoxications afford a 
favorable basis for them. Later we will have to return to 
the content of visions. We will find them, like the pho- 
nemes, to be definitely dependent on the patient’s affects. 8 
Outlines of Psychiatry in Clinical Lectures. 
Patients of intelligence and judgment, who can express 
themselves, claim their visions exercise an influence over 
attention. Thus e. g. a patient perceived the form of a 
man at a certain place in the room at night. She must 
gaze at him, could not take her eyes off him and watched 
him as he slowly approached the bed and bent over her, it 
all being accompanied by a feeling of anxiety gradually 
intensified to an intolerable degree, in delirious patients 
the visions are often accompanied by this feeling of 
anxiety, when, if not rare, the delirium is of an anxious 
character. The content of the visions then corresponds: 
the devil comes to get them, hell opens, an abyss yawns 
at their feet, the walls are tottering, the roof threatens to 
fall, etc. In melancholic conditions we meet with isolated 
hallucinations, which are a true imitation of the prevalent 
feeling of misery; deceased relatives, corpses, a coffin, a 
whole funeral procession. 
Visions are also accurately projected to definite places 
in space, so far as they have been particularly described. 
You will remember the patient with numerous and most 
diversified visions, who definitely stated the picture had 
been about one and one-half feet away from him and on 
the whole no larger than a plate; nevertheless he had seen 
and recognized an entire landscape, the shore of a river 
and the form of a comrade bathing. When patients speak 
of shadows we sometimes meet with the statement that 
their visions are transparent, as one patient described the 
vision of a deceased relative. 
Hallucinations of sight are more rare by far than the 
phonemes, and their clinical importance can in no way be 
compared with the latter. As they do not usually possess 
the complete stamp of reality they do not have the disor- 
ientating or confusing effect of the phonemes. Nevertheless 
they are very often the source of explanatory ideas, which 
vary in color according to the personality. As you remem- 
ber our engineer K hesitated between the assumption of 
witchcraft and the other that the spirits heard by him 
would intentionally make him the witness of different 
events of the visions he described. C. Wernicke. 
9 
Hallucinations of the tactile sense, perhaps more cor- 
rectly of the cutaneous sense, are the most common in 
delirium tremens. The patients feel animals creeping over 
the body, either vermin or reptiles, like snakes, lizards, 
toads, etc., and they constantly try to brush them off. 
Such hallucinations also occur alone in other acute mental 
diseases. Still more often they are of a more definite form, 
consisting of the feeling that the patient’s fancy they are 
being covered with a powder or vapors blown on them, of 
course of a harmful nature. This hallucination is very 
common in chronic patients who usually belong in the cat- 
egory of hypochondriacal delusions of persecution. An 
abnormal feeling of heat of the skin may be the cause of 
delirious and excited patients trying to remove their cloth- 
ing. The prickling sensation, so accurately described by 
many insane and interpreted that they are being magne- 
tized, further the pathological feelings of heat and cold are 
also to be included among the hallucinations of the cutane- 
ous sense, while pricks, blows, cuffs and other pains repre- 
sent hallucinations of general sensation. 
Hallucinations are often not confined to one sense, but 
several are affected. The combination of hallucinations of 
taste and smell is the most frequent. The natural result 
of this combination is, that the pathological perception in 
one sense is regarded as verification of the hallucinations 
in the other senses. A certain uniformity of the hallucina- 
tion is thus presumed, so that sensations belonging to two 
different senses combine in the same way as actually 
occurs in the perception of definite concrete things. But 
this process seems to be the rule in combined hallucinations. 
Simple combinations, like those of taste and smell just 
described, are especially frequent in the senses which are 
noted for active organic sensations, so besides those men- 
tioned, those of contact and the so-called hallucinations of 
general sensation, which we will later consider fully. Those 
combinations are conspicuous in their manifestation, which 
occur in the so-called higher senses and are accordingly 
characterized by the prevalence of the sentient content. 
The most perfect deceptions as to reality arise by the 10 
Outlines of Psychiatry in Clinical Lectures. 
co-operation of hallucinations of hearing, sight and contact. 
The patient believes he is transferred to a definite place 
and surroundings, e. g., home in the midst of his family or 
to a cemetery during a funeral. He then sees persons act, 
hears them speak, and various noises like the rumble of 
carriages, dirges, etc., in short, the whole affair is reproduced 
somewhat as on the stage, where the patient may even 
take part. When the hallucination is past, the patient 
sometimes states he has come to himself, or it had seemed 
to him as though he had been in those surroundings, state- 
ments which permit the conclusion of a certain insight into 
the pathological nature of the manifestation. The combined 
false sensations of the delirious patient are similar, who 
fancies he sits on the box as coachman, sees the horses 
and street before him, calls to others to get out of the way, 
hears the horses neigh and the people shout, and is still 
really in bed in the hospital. With the exception of delir- 
ium tremens, these combined hallucinations are rare in the 
insane, whereas they are peculiar to and characteristic of 
febrile states in severe somatic diseases like typhoid, cer- 
tain brain diseases, meningitis and certain acute states of 
inanition. Their preliminary condition in all these cases 
seems to be a more or less pronounced degree of confusion 
and blunting of the sensorium. As they also in their mode 
of manifestation have the greatest similarity to the false 
sensations in dreams, we may properly call them dream-like 
hallucinations. Epileptics and hysterio-epileptics may be 
subject to such dream-like hallucinations for hours and 
days, they occasionally appear in states of pathological 
intoxication, as after administration of ether, chloroform, 
belladonna and similar substances. In persons of markedly 
nervous constitution they may occur alone, without being 
followed by a mental disease. 
As Kahlbaum states, it quite often happens that these 
dream-like hallucinations escape medical observation and 
may only be subsequently disclosed by the patient’s state- 
ments. It is then improper or only in the cases just 
described to conclude the actual presence of hallucinations, 
it often being rather a matter of the familiar phenomena C. Wernicke. 
11 
of additive false memories. Another combination of hallu- 
cinations, which does not belong to the dream-like, deserve 
mention owing to their frequency. They consist in hallu- 
cinations of other senses or in that of hearing being 
interpreted, confirmed and eventually put into words by 
“voices.” So e. g. nothing is more common than that 
patients with hallucinations of taste and smell sometimes 
hallucinate the words poison, human flesh, etc., or that 
patients with abnormal physical sensations give to the hal- 
lucinations of hearing definite terms, technical expressions, 
which they ever after use. 
The comprehension of hallucinations as symptoms of 
the acute psychoses is of so great importance that 1 cannot 
help prefacing our theoretical discussion by a few historical 
remarks. The oldest theory of hallucinations, which has 
prevailed for a long time, was evolved under the influence 
of the great physiologist, Johannes Muller and is derived in 
the simplest manner from the physiological process of per- 
ception. It starts from the fact that normally we are able 
to accurately differentiate many pictures, (pictures of the 
imagination) from actual perceptions. But the difference 
consists physiologically in that an irritation of the sense 
organ, respectively sensory nerve, always occurs in the per- 
ception. Then if one will accept as their explanation, what 
is not to be avoided from the nature of hallucinations, an 
excitation of memory pictures (pictures of the imagination), 
it will then be a hallucination only when a pathological 
stimulation occurs simultaneously in the periphery, i. e., in 
the sensory nerve, so that this latter forms the preliminary 
condition of the hallucination. Owing to this view the 
theory of hallucinations has been preferably cultivated, so 
that diseases of the sense organs or sensory nerves, which 
could have a stimulating effect, have been sought for. But 
only very exceptionally has it been possible to demonstrate 
such changes in the sense organs or nerves, and many 
apparently confirmatory data awaken doubts as to the cor- 
rectness of this theory. Thus in hallucinations of sight 
the optic nerves have been found with gray degeneration 
and transformed into a mass of connective tissue, and also 12 
Oittlines of Psychiatry in Clinical Lectures. 
in cases in which a very long existence of this change was 
to be proven before the advent of the hallucinations. It is 
similar in other cases of blindness owing to destruction of 
both bulbs. It seems extremely artificial to assume in such 
cases of years of inactivity of the optic nerves, that they 
could resume their function with the onset of a mental 
disease, or that irritative phenomena could have originated 
from the affected area, of which nothing has been previ- 
ously noticed. The consequence of this difficulty was, that 
the requisite stimulus from the sensory nerves was located 
at their central terminal, and according to one, in their so- 
called nuclei (Schroder v. d. Kolk), according to others in 
the optic thalamus. Still it was as good as proven anatom- 
ically (by Luys), that the optic thalamus is a central 
station of all sensory nerves. This assumption first 
advanced by Hagen has the most adherents. Its latest and 
most active advocate, in only a slightly modified form, is 
Meynert. His opinion may be expressed somewhat in the 
following terms: When an insane person has a hallucina- 
tion and, in spite of his other senses functionating normally, 
he does not perceive the pathological and subjective nature 
of his deception, this indicates a certain weakness of the 
intellect, respectively of the function of the hemispheres. 
The hemispheres are not only the organ of the intellect, 
but they have a second cardinal function, which consists in 
the inhibition and suppression of automatic and reflex irri- 
tative processes in the subcortical ganglia. A blunting of 
the function of the hemispheres causes a diminution of this 
inhibition and will therefore so act on the subcortical 
ganglia, that irritative processes occurring in them may be 
increased to the degree of stimuli coming from without. 
The hallucinations are thus explained by a state of irritable 
weakness, in which the irritation and weakness are assigned 
to two different localities. This hypothesis is defective in 
that it rests on a number of other hypotheses: thus on the 
assumption of pathological irritation in the subcortical 
ganglia, for it must be present to be increased to a patho- 
logical intensity; further on the assumption that the func- 
tion of the hemispheres is blunted in patients with halluci- C. Wernicke. 
13 
nations. We will see later that this assumption is wholly 
superfluous. But if it should be accepted exactly as 
expressed in Meynert’s line of thought, to consider the fact 
of the mutual inhibition of the functions of the hemispheres 
and to see the apportionment of these two opposite condi- 
tions within the hemispheres, so that the weakness of 
function would have to be considered allotted to the other 
parts of the hemispheres, while the increased function to 
the central projection fields of the sense concerned. There 
is no necessity for the further assumption of a state of 
irritation in the subcortical ganglia. 
If 1 am compelled to take a position adverse to Mey- 
nert’s hypothesis, 1 have to guard against a possible 
misunderstanding; 1 am far from mistaking that the hypoth- 
esis of this talented master finds its real foundation in his 
special view of the agency of the vascular system in the 
brain mechanism, and that 1 have singled out only one link 
in a chain of hypotheses, whose strength lies in their firm 
structure. But the purely descriptive tendency of our clin- 
ical studies compels us to waive all hypotheses not 
unconditionally necessary. Besides justice requires the 
mention of two of Meynert’s predecessors in his line of 
thought. In his work previously mentioned Kahlbaum pre- 
sumed, on the strength of Schroder v. d. Kolk’s anatomical 
views, the seat of the stimulation in hallucinations of a 
definite kind to be in the subcortical centres and the 
primary nuclei of the nerves. And finally we have to 
mention H. Neumann’s purely psychological statement. 
Neumann explains hallucinations by the suppression of that 
normal function of the brain, which he designates as criti- 
cism. He describes them under the disorders of criticism. 
That this conception, which is devoid of all attempts at 
localization, is completely covered by Meynert’s hypothesis, 
that the function of the hemispheres (which is manifested 
as criticism) is blunted, is readily conceivable. Neumann’s 
method of consideration is at least characterized by great 
impartiality. 
These brief remarks on the history of hallucinations 
may suffice to show, how in consequences of Johannes 14 
Outlines of Psychiatry in Clinical Lectures. 
Muller’s original assumption, authors have been obliged to 
go ever farther centrally and to locate the pathological 
stimulus from the sense organ and sensory nerve in the 
nerve center and then in the next higher station of the 
subcortical ganglia. Therefore, a co-operation of the central 
projection fields is indispensable, for the presumed stimuli 
from the subcortical ganglia, if simple note should be taken 
of them, could not possibly have the coordinated character 
of real perceptions presuming an action of association. 
Our position with respect to the question is simply 
stated by the points of view I have evolved in my intro- 
ductory lectures.* The difference between the memory 
picture and the idea is effaced in the hallucination by a 
pathological process. We have already found this difference 
to be that the first terminal station of the projection system 
in the central projection fields of the cortex, which we have 
called “projection cells,” are also stimulated in the act of 
perception. We have become acquainted with these cells 
as the embodiment of the organic feeling and constituents 
of the consciousness of corporality. We will therefore be 
able to characterize the nature of hallucinations, by saying 
the pathological stimulus extends beyond the memory pic- 
tures to this embodiment of organic feeling, and a memory 
picture becomes an idea and consequently the hallucination, 
as soon as it is supplied with the inherent organic sensa- 
tions—by excitation of these projection cells. It is then an 
affection of the consciousness of corporality, which consti- 
tutes the cardinal trait of hallucinations. The cardinal 
attributes of hallucinations just evolved become intelligible 
to us. Thus primarily the force they exercise on attention. 
Every intense organic sensation exercises this force, as 1 
have shown you in different examples,! and that this force 
is likewise to be regarded as a protective measure for the 
aggregate of corporality, Meynert’s primary 1, you will also 
remember. It is now comprehensible why the affect of 
anxiety shows such a close connection, often a direct 
dependence on the hallucinations. This affect always 
♦See Alienist and Neurologist, Vo!. XX, p. 155-169, 355-365. 
tSee Alienist and Neurologist, Vo!. XX, p. 357. C. Wernicke. 
15 
occurs, as you remember, when the corporality, the “primary 
I,” is jeopardized. 
The remarkable observations of abnormally sharp 
localization of the hallucinations are comprehensible. The 
organic feeling, as constituent of the general feeling of cor- 
porality, is always referred to a definite place in the sensory 
layer of the skin, the retina or the epithelial layer covering 
the other sense organs. In the retina a very definite pro- 
jection space is due to this, an attribute which, as we have 
seen, constitutes vision. It has further been proven that 
the adaptive movements of the eyes must be accompanied 
by organic sensations of the retina. We observed such 
adaptive movements of preformed kind in respect to the 
organ of hearing in all animals with movable auricles, and 
the remnants of motility of the ears, which man still pos- 
sesses, are an evidence that man could once make such 
adaptive movements. It is reported of savages that their 
greater keenness of hearing renders them capable of local- 
izing the origin of tones and sounds in surprisingly exact 
manner. This attribute is wanting in civilized mankind. 
But we see it occur in cases of illness and, as seems per- 
fectly comprehensible, joined to abnormally intense organic 
sensations, which in part are felt to be directly annoying 
and so take the attention that the patient is compelled to 
listen to a hallucinatory whispering, although he cannot 
understand a word. As we will see later, abnormal localiz- 
ations of phonemes occur, e. g., within the body, in one leg 
or in one boot, as a patient said. We will now and then 
find the effect of anxiety localized in this remarkable way. 
We must perceive in this examples of pathological associa- 
tion in the consciousness of corporality and no longer regard 
them so strange. 
(To be continued.) W EtfNICrfEr (c.) 
THE 
Alienist and Neurologist. 
VOL. XXIII. ST. LOUIS, NOVEMBER, 1902. No. 4. 
OUTLINES OF PSYCHIATRY IN CLINICAL 
LECTURES.* 
By DR. C. WERNICKE, 
Professor in Breslau.t 
Lesson from hallucinations continued—Stability of preformed association 
bonds—Participation of the projection fields in hallucinations—Special 
localization of memory pictures—Paraphasic speech impulse of 
paralytics, compulsory repetition of phonemes—Different 
intensity of memory pictures—Hypermetamorphosis— 
Hyperesthesia—Modification of the scheme of 
identification disorders. 
LECTURE TWENTY. 
THE conception just evolved seems to encounter an 
obstacle which merits our consideration. How is it 
possible, we may ask, that a pathological stimulus, whose 
localization is in a certain measure subject to chance, 
repeats that order of stimulation which appertains to a 
definite optical memory picture, or such an artificial group- 
ing of individual impressions as belong to the acoustic 
memory picture of a word or a melody? Might it not be 
♦Continued from the Alienist and Neurologist, Vol. xxiii. No. 3. 
•''English by Dr, W. Alfred McCorn. 2 
C. Wernicke. 
expected that a pathological process acting at once, depend- 
ent on the chance of the affected area, might result in a 
wholly anomalous stimulation of the perception cells con- 
cerned of the central projection field in no way correspond- 
ing to the functional unity of the memory pictures and the 
concrete concepts? Still this obstacle is encountered more in 
dream-like or some combined hallucinations than in single 
hallucinations of one sense. We must perceive the pecu- 
liarity of these dream-like hallucinations consists in the 
stimulation inducing the hallucination occurring similarly, i. 
e., with that arrangement of the stimulus which reflects an 
exact picture of the reality. In fact we cannot dispense 
with a hypothesis for the explanation of this remarkable 
coincidence, which 1 have previously indicated*, when I 
said the experiences of the clinic necessitate transferring 
the proposition of the specific energy of the sense elements 
to the whole association organ and assuming that in the 
unison of the same combination of associative elements the 
same psychical process always occurs. We had formerly 
employed this only so far, that we explained the appear- 
ance of definite thoughts as such a unison of a very defi- 
nite combination of associative elements. We will now 
have to go a step farther and consider the origin of dream- 
like hallucinations to be a unison of these functional units 
by some special stimulus. In other words: in whatever 
way a stimulus may act on the elements united by repeated 
function and usage of functional units, the effect is always 
the production of a definite, specific content. Thus the 
simultaneously combined hallucinations afford us an example 
of the stability of these functional unions,! which represent 
the picture of the world. The consideration just advanced 
is especially applicable, when it is the matter of the irrad- 
iation of some stimulus to the intact central projection 
fields, while disease of the projection fields is able to pro- 
duce pathologically changed hallucinations. Thus we 
understand A. Pick’s remarkable observation in an individ- 
ual who formerly had sensory aphasia. The hallucinations 
*See Alienist and Neurologist, Vol. xxi, p. 3. 
f'Merksystemen” nach G. Hirth. Epigenesis der Merksysteme.Munich, 189.7. Outlines of Psychiatry in Clinical Lectures. 
3 
of hearing here had a pronounced paraphasic character and 
consisted of distorted words, sentences of disconnected 
words, etc. The same author reports a patient with hemi- 
optic defect of the homonymous quadrants of both visual 
fields. This patient’s hallucinations of sight had the pecu- 
liarity that they had defects corresponding to the quadrants 
affected, so that for instance a head appeared with a corre- 
sponding sector missing. In progressive paralysis, that 
disease which always leads to a local disease of the pro- 
jection fields, distorted or entirely senseless words are often 
hallucinated, but also elementary sounds which might owe 
their origin to the irregular local irritative effect on a dis- 
eased projection field. Optically the most diverse manifes- 
tations of light, visions of lightning and balls of fire, are 
observed, whereas the great majority of hallucinations are 
certainly to be ascribed to the irradiated irritative effects, 
for brain pathology teaches that the largest number of irri- 
tative symptoms depend on a transmission of the irritation 
from parts of the brain often remote. 
According to the view just advanced we will not hesi- 
tate to regard hallucinations localized processes and to 
presume their seat to be in the projection fields of the 
senses affected. We are obliged to locate the first stimu- 
lation process in that locality, which corresponds to the 
memory pictures and to take from them a further stimula- 
tion of the proper perceiving elements arranged according 
to the norm of the projection system, “perception cells” as 
we formerly called them. This conception must, as is 
readily seen, support that hypothesis which locates the 
memory cells, not at the point of perception, but in other 
parts of the cortex, a hypothesis that has essentially gained 
in probability by a paper from my clinic by H. Sachs.* As 
you remember in my introduction I represented, as the 
essential factor of the memory picture, the form of the 
stimulus, i. e., the mutual relation of the stimulated percep- 
tion cells, and Sachs has proven, or at least made very 
probable, that the memory of this relation in the sense of 
*Die Entstehung der Raumvorstellung aus Sinnesempfindungen. Psychatr. Abhand- 
lung, von C. Wernicke, Nr. 5. 4 
C. Wernicke. 
sight is not to be considered represented in different ele- 
ments of the light field so called by him, the cortical 
termination of the optic tract, but in the motor oculi pro- 
jection field. We might regard vision as the result of the 
process of sejunction, definite motor oculi memory pictures 
are excited and from there the coordinated precipitating 
elements of the light field so-called. This second act is 
involuntary, and we must hence conclude that only a stim- 
ulus of pathological intensity can overcome the obstacles 
opposing the enforced inversion of the direction of conduc- 
tion. That these obstacles are very important, we conclude 
from the fact that most visions are described as shadowy 
and slightly luminous, while the other fact that they usu- 
ally appear superficial and like pictures, indicates that the 
transmission of the stimulus from the motor oculi field to 
the corresponding one of the other hemisphere does not 
ordinarily occur—perhaps because no preformed path exists. 
We cannot generally expect from a stimulus due to patho- 
logical processes, that it is manifested symmetrically at 
identical places in both hemispheres, or we will admit this 
as possible only exceptionally and under certain conditions. 
For the estimation of depth, in so far as it is ascertained 
by the eyes, the cooperation of the motor oculi projection 
fields of both hemispheres will always seem essential. You 
see that the hypothesis of a more or less voluntary local- 
ized pathological stimulus affords the simplest explanation 
of certain fundamental attributes of hallucinations of sight. 
Of course the other possibility is not to be overlooked,that 
a pathological stimulus is exceptionally manifest in the light 
field: we then have so-called elementary hallucinations, 
manifestations of light of the most diverse sort, in which 
form is secondary. When anyone sees lightning, a cloud 
of fire, a flaming sword, a sea of fire or refuses the milk 
because he takes it for blood, or sees pools of blood in his 
bed, it is a matter of these primary stimulations of the 
light field—of course in consequence of the sejunction 
process. 
That a similar consideration applies to the memory 
pictures of tones and speech sounds, H. Sachs has cleverly Outlines of Psychiatry in Clinical Lectures. 
5 
shown in his paper just mentioned. Here in the memory 
pictures the relation of tones and sounds to each other is 
decisive, and therefore probable that these relations of 
magnitude are joined to a motor acoustic projection field 
corresponding to the motor oculi. The transmission of the 
pathological stimulation from this supposed field to the 
acoustic projection field conditions the occurrence of the 
hallucination and, as the great majority of relations of mag- 
nitude represent speech sounds, the subjective cause of 
speech sounds. In the exceptional case that the acoustic 
perception field is primarily affected by the stimulus, sub- 
jective noises and tone combinations of irregular quality, 
the akoasmas so-called, arise. That hallucinations of hear- 
ing and especially the phonemes, contrary to hallucinations 
of sight, have the complete stamp of reality, it is compre- 
hensible from the fact, that the centre of word sound 
images is located on one side, so that in the phonemes we 
have an exquisite focal symptom of the left temporal lobe, 
at least of limited localization value, which irritative symp- 
toms possess in themselves. This value materially 
increases as soon as to the symptoms of stimulation are 
added those of defect, and therefore this is the place to 
call to mind the occurrence of maniacal aphasia,* as I called 
it. We will see later that this name may no longer seem 
applicable, for it is more a matter at the same time of a 
hyperkinetic and parakinetic symptom. This symptom is 
that of the paraphasic speech impulse occurring quite often 
in paretics, an exquisite motor symptom of irritation, in 
which the defect, the disease of the first left temporal con- 
volution, is manifested in the paraphasically altered form of 
the speech impulse. Contrary to the other isolated speech 
impulse of the paretic without paraphasic complication 
occurring quite frequently, which is a true maniacal symp- 
tom, this speech impulse also has in content a large motor 
stamp and doubtless depends on an irritative effect, which 
has its starting point in the affected left temporal lobe. 
We then perceive that any stimulation of the left temporal 
lobe may act in an entirely different way, in a certain 
*Gehirukrankheiten 3, Bd., p. 551. 6 
C. IVernicke. 
measure contrary to that in the acoustic projection field, 
and that the irritative effect in these cases uses the pre- 
formed path to Broca’s convolution. 
Another fact deserves mention under the same point of 
view as the localization of the effect of irritation; 1 refer to 
the quite common imperative repetition of phonemes. This 
exquisitely motor symptom, which under certain conditions 
may be combined with paraphasia, points to an irritative 
effect, which belongs to one of the two kinds of irradiation 
familiar to us. It has the peculiarity, that the content of 
the phonemes very often consists in affectless series of 
associations learned by heart, e. g., in the repetition of the 
multiplication table. As much as this circumstance speaks 
for a strict localization of the stimulus in the temporal 
lobes, these cases in no way belong to paresis, but to the 
motility psychoses, and this is true of imperative speaking 
without previous hallucination of the speech sounds. 
You see that the knowledge of all these inwardly 
homogeneous symptoms places in the correct light the 
importance of the first left temporal convolution as seat of 
the phonemes, the most frequent and, 1 may almost say, 
the most important of psychotic symptoms. Nevertheless 
we cannot doubt that, excepting certain special cases, as 1 
have in part indicated, the left temporal lobe is not the 
real seat of the disease processes, whose irritative effects it 
manifests. The phonemes are rather to be regarded largely 
as reflex or secondary effects, at any rate manifestations of 
irradiation from other localized disease processes—sejunction 
processes. This is proven by the one, at least funda- 
mental fact, that exactly the same disease types may occur 
either with or without phonemes. The phonemes then 
show that they are replaced by a corresponding content of 
thought, if not put in the exact words. Besides from the 
further fact that the content of the phoneme conforms to 
the type of disease, is like the content of thought. We 
will soon have to go into this point more fully. 
You see that any attempt to obtain a better under- 
standing of the psychoses leads us to certain important 
questions in brain pathology, as e. g., that of the special Outlines of Psychiatry in Clinical Lectures. 
7 
localization of memory pictures. In my opinion this is now 
quite probable, not only from the properly presented theo- 
retical statements of H. Sachs, but also from the observa- 
tions, if still few, in which cases of asymbolia so-called has 
been carefully investigated and a careful autopsy made. 
Three such cases from my clinic, two with autopsies, have 
recently been described by Heilbronner* in my psychiatric 
papers, and asymbolia accordingly represented as a com- 
bined disorder, in so far that secondary identification is in 
part lost, in part the primary identification of the sense 
impressions. The first condition is explained by the 
autopsy from the bilateral breaking up of the medullary 
layer of the convexity of the brain mantel, between the 
occipital and temporal lobes on one side and the other parts 
of the brain on the other. The disorder of primary identi- 
fication is amply explained by the partial destruction of the 
occipital and temporal lobes. Therefore the clinical pre- 
sumption for the symptom complex of asymbolia, namely 
the integrity of the real act of perception is also confirmed 
by the autopsy, in that the light field of the occipital lobe, 
as Sachs calls it, and on the other hand the great part of 
the temporal lobe, are retained and still combined with the 
projection fibres. To make my position plain in this mat- 
ter, 1 will at once state that I attribute the act of functional 
transmission from the perception to the memory centres to 
primary identification and will alone recognize the transcor- 
tical transmission of the stimulus to the latter as secondary 
identification. Also the autopsy of the case of mind blind- 
ness closely observed clinically by Lissauer,f anatomically 
investigated by Hahn,t supports this assumption. 
A second equally important question, in which psychi- 
atry is largely interested, is whether thoughts occur in 
words or concepts or largely in one of these forms. As 
you remember 1 have previously said, that thought is never 
exclusively associated with the presence of word concepts 
or images of word sounds only, that independent thought 
*Psychiatrische Abhandlungen, Heft 3 and 4: Asymbolia. 
tArch, f Psych. 21 Bd. 
JArbeiten aus der Psychiatr., Klinlk in Breslau, Heft II, Leipsic, 1895, p. 105. 8 
C. Wernicke. 
in concepts is to be admitted. However, I might previously 
have stated that individual variations in this respect may 
exist, in a certain measure brain habits, accordingly some 
think largely in words, others in concepts. I fancy think- 
ing largely in concepts is the deliberate, in a certain 
measure, scientific form of thought more exactly suited to 
reality. But I cannot deny that eminent brain experts like 
H. Sachs advocate another view and, so to speak, locate 
wholly logical thought at the seat of sound images, i. e., 
in the left temporal lobe. As 1 have previously stated, this 
goes too far in my opinion and is contradicted by clinical 
experience in diseases in the left temporal lobe, but I must 
admit that, irrespective of an individual variation, a series 
of concepts exist, which in my opinion may be especially 
connected with the left temporal lobe as the seat of the 
word memory pictures, and therefore because, contrary to 
the other and especially all concrete concepts, the neces- 
sary word sound image affords in a certain measure the 
only rendezvous of all accompanying associative combina- 
tions, because further these latter are all acquired by 
means of speech. I do not mean by this the expressions 
for states of internal experience, which I have previously 
cited, but more artificially learned concepts acquired by 
instruction and in no way the abstract alone. This includes, 
e. the numerals and their use, as well as concepts of 
historical dates and personalities combined with definite 
names, and actually many that are abstract. A thought 
which is independent of the left temporal lobe we will only 
be able to conceive of under the limitation to largely con- 
crete concepts, we say with a certain simplification of the 
content of thought. In general the object of clinical psy- 
chiatric observation, namely the motor relation of certain 
external conditions, makes no essential claims, the less so 
as more acute the disease is, so that we can then actually 
take account of the accepted individual variation of differ- 
ent persons. 
At least 1 know for a fact, that for a whole series of 
mental diseases, which occur at one time with, again with- 
out hallucinations—and it is always a matter chiefly of Outlines of Psychiatry in Clinical Lectures. 
9 
phonemes—there is no other explanation than this individu- 
ally different habit of thought, which in those thinking 
largely in words explains an increased excitability of word 
sound images and hence the readier occurrence of hallu- 
cinations. 
If a doubt is possible whether thought occurs exclusively 
in memory pictures of words, it is wholly impossible to deny 
that one thinks chiefly in memory pictures, and that for the 
differentiation between a memory picture and an idea we must 
possess an absolutely reliable sign derived from internal ex- 
perience. But it is a question how memory pictures of differ- 
ent intensity are estimated by us,and whether in this respect 
perhaps the elementary symptoms of autochthonic thoughts, 
imperative conceptions and quantivalent ideas permit of a 
closer analysis. Of these three symptoms the imperative 
conceptions are evidently the best known and most readily 
separated. But in the acute psychoses their clinical impor- 
tance is relatively small. The quantivalent ideas, as we 
shall soon see, require a certain broadening of their defini- 
tion. Then it is clear that they can claim a significance 
similar to hallucinations in the clinical picture of the acute 
psychoses. Of the autochthonic ideas, we have already 
seen that they are closely related to the phonemes, may 
precede or pass into them and occasionally are not to be 
separated from them, in that the patients do not know 
whether a real vocal sound is present in the prompted 
thought or not. The relationship now becomes more evi- 
dent, in that the autochthonic ideas always seem to be put 
into definite wo:ds and that they have according to their 
content the same significance, as is especially clear, when 
the content corresponds to a command or interdiction and 
affects the patient's action. 
The factors cited permit the interpretation that the 
autochthonic ideas, '.ike the phonemes, are an irritative 
symptom of the temporal lobe, i. e., an appearance of very 
vivid memory pictures of word images, without the irritation 
extending to the organic sensations of hearing. The like 
intensity of the pathological irritation presumed, would then 
necessarily result in the further hypothesis, that the irrita- 10 
C. IVernicke. 
tive process, which may extend to the seat of the organic 
feeling, i. e., the acoustic perception field, must have— 
functionally—origin nearer the temporal lobe, than another, 
which is exhausted at the seat of the memory pictures. 
We thus arrive at the assumption, which I have previously 
given you, that the difference in the localization of the 
sejunction process is the basis of the difference between 
hallucinations and autochthonic ideas. 
1 have already intimated that primary identification in 
the insane may be affected sympathetically. The two 
symptoms, which are here to be considered, relate to ihe 
real boundary between secondary and primary identification, 
namely the organic feeling adhering to the “perception 
cells,” and it is not chance that they are chiefly observed 
in pathological states, which in their whole character are 
close to the so-called “organic” diseases of the brain and 
nerves. 
By hypermetamorphosis we understand the organic 
impulse to notice sense impressions and take the attention. 
It may usually be shown experimentally, in that some 
sensory stimulus is brought near the patient, e.g., shown 
the watch, the handkerchief, the purse or some object acci- 
dentally manipulated, for the sense of sight1 produce a 
noise, like the clock striking, making a half audible remark 
to a third person, letting the water tap run, humming a 
melody, for impressions of hearing; incidentally touch the 
patient, for tactile impressions; bring odorous substances 
near him, for impressions of smell. The patient’s whole 
conduct may usually prevent the symptom unmistakably 
and immediately, and especially it is the occurrences on 
the ward, which imperatively claim the patient’s interests. 
Still a distinction with respect to the sense is often plainly 
shown, in that many patients are more attracted by visual 
impressions, many more by the acoustic, especially in the 
patient’s manifestations. We find an explanation of this 
symptom in the assumption of an increased excitability of 
the organic sensations, so that the innate attribute of 
attracting the attention is manifested in weaker, otherwise 
unobserved sensory stimuli. That in such exaggeration of Outlines of Psychiatry in Clinical Lectures. 
11 
the organic sensations, the quietest surroundings with the 
most monotonous impressions offers the patient sufficient 
and more than enough material for the sense impressions, 
is comprehensible. The most suitable place for such 
patients is therefore in seclusion, for the symptom is of 
essential practical importance, because it can produce,main- 
tain and increase a patient’s motor restlessness, irrespective 
of the fact that the other patients may be disturbed, 
annoyed and affected sympathetically. The cardinal sequela 
of hypermetamorphosis is the distraction, i. e., the faulty 
pliability of thought and the patient’s inability to follow a 
certain train of ideas. The patient’s answers, the informa- 
tion he will give of his own accord, may therefore have 
the appearance of being incoherent, because he is interrupted 
every moment by existing sensory impressions. Hyper- 
metamorphosis is therefore a cardinal element of those 
symptom complexes, which we will later become familiar 
with under the name of confusion. In this symptom com- 
plex it may occasionally be the decisive and controlling 
element, but hypermetamorphosis is unable to form* a real 
disease type, it always seems to be an attendant, if impor- 
tant symptom in this respect. 
Hypermetamorphosis is the most closely related to the 
so-called liypercesthesia of the sense organs,a symptom which 
is common to many physical diseases. Hyperaesthesia is 
in no way identical with hypermetamorphosis and must 
not be confounded with it. In the insane it has only a 
slight and almost never independent significance, at most 
only in those chronic insane, who must be considered tran- 
sitional forms to the hysterical type, then almost exclu- 
sively in hysterical women. Further it perhaps causes the 
symptom of timidity in certain dazed conditions common to 
epileptics, which owing to the evident blunting of the sen- 
sorium and their stuporous character, present a great simi- 
larity to well known symptoms of organic brain disease 
(especially meningitis). The timidity of certain very acute 
types of mental disease, which we will become acquainted 
*The discoverer of the symptom, H. Neumann, has advanced such a disease type, but 
in combination with so many other elements, that It can only support my claim. 12 
C. Wernicke. 
with later, probably depend in part on this, irrespective of 
the hyperaesthesia of the sense organs being observed par- 
ticularly in the first increasing stage of acute psychoses 
and in their convalesence, when it renders the patients more 
or less intolerable and dissatisfied or irritated by the im- 
pressions from their surroundings, according to the 
personality. 
The two symptoms just described cannot fail to remind 
you of what was formerly said in attempting to define 
mental diseases and separate them from brain diseases. If 
hypermetamorphosis depends on an increased excitability, a 
permanent irritable state of the perceiving elements, per- 
ception cells as we have called them, it does not belong to 
the disorders of secondary identification, but has its seat in 
the next terminations of the projection system. This is 
true of the hyperaesthesia of the sense organs, when its 
cause is not to be sought in a peripheral portion of the 
nervous system, what may be the case in all those instan- 
ces, where the hyperaesthesia is manifested in only one 
sense. Therefore hyperaesthesia has always been described 
among the disorders of the peripheral nervous system, 
whereas hypermetamorphosis is always of central origin. 
Clinical observation confirms our conception, in so far that 
we will meet the symptom especially in the severe patho- 
logical states, irrespective of its uncommonly frequent 
occurrence in the agitated forms of paralytic psychoses. 
Among the non-paralytic psychoses it is particularly the 
two types of disease of confusional mania and the hyper- 
kinetic motility psychoses, where the symptom is almost 
never absent and constitutes a very essential component of 
the disease type. 
It will not seem strange that our scheme sAZm permits 
the deduction of certain boundary cases, in which the 
principle of secondary identification is violated and a tran- 
sition between primary and secondary disorders of identifi- 
cation seem to occur. We will then have the same expe- 
rience in the matter of motility, where we will meet with 
slates of muscular rigidity accompanied by profound uncon- 
sciousness, which form a decided transition to epileptic Outlines of Psychiatry in Clinical Lectures. 
13 
seizures, and yet according to their development can only 
be regarded as a specially violent exaggeration of symptoms 
of hyperkinetic and parakinetic motility in the course of 
severe psychoses of motility. We will quite often meet 
with the development of actual contractures as the result 
of habitual parakinetic identification disorders in the psy- 
chomotor domain. Our scheme also shows how universally 
nature does not go to work schematically. We must always 
remember that every scheme, and ours as well, only pos- 
sesses the value of a means of instruction and explanation 
and is superfluous as soon as a better, easier or more 
correct grouping the facts is found. Rely upon it, no one 
is more imbued with this necessity than 1, and that respect 
for the facts in this attempt to clinically present the mental 
diseases is my chief incentive. 
We will now understand that we have the right to 
change our scheme as necessity demands without being 
accused of being illogical. This is the proper place to 
ascertain as to how far such a requirement exists. 
I must still remind you of my introductory remarks as 
to organic sensations and the consciousness of corporality. 
We had then become acquainted with certain motor mani- 
festations, which we have interpreted as protective measures 
for the body and traced them to preformed, probably inher- 
ited* mechanisms. Such movements were in part of a 
simple nature, like congenital reflexes, e. g., the adaptive 
movements of the eyes, the withdrawal of a limb from a 
painful irritant, in part complex motor coordinations, like 
those of recoil, dodging, etc. Such movements have the 
common characteristic that they occur as reaction to active 
organic sensations, and half unconsciously, at least without 
any complex mental action. Experience teaches that these 
movements occur in the insane, and our scheme is not, or 
only under considerable constraint applicable to them. The 
change in our scheme, which is here necessary is merely 
that we consider given a sort of cortical reflex, a short cut, 
to use a comparison, to one of the shortest paths between 
s and m, a path which wholly belongs to the consciousness 
*Epigenetic medullary system according to G. Hlrth’s happy expression. See ''Epi- 
enesis der Merksysteme, Munich, 1898. 14 
C. Wernicke. 
of corporality and is relatively independent of further action 
of the organ of consciousness. We thus arrive at an 
explanation of a series of motor manifestations, which, 
according to their form, are known to us as reaction to 
intense organic sensations from normal mentality and are 
observed in the insane under conditions which permit the 
conclusion of an extreme blunting of the sensorium. 
Thus e. g. the wallowing or agitated movements resem- 
bling jactation, often perfectly identical with it, in many 
profound dazed conditions of epileptics and paralytics, occa- 
sionally lasting for several weeks, continual and always of 
the same monotonous mode of execution. More definite 
motor coordinations are occasional, like those of twisting 
(under pain), doubling up, which point to active organic 
sensations in the intestines, without there being a doubt as 
to their central mode of origin. We will then presume the 
same mode of origin, when the patients are conscious and 
also able to inform us at once or afterward of the organic 
sensations that were the cause of their movements. The 
expressive movements, like crying and howling, often with 
all the force possible, are observed in consequence of a 
feeling of anxiety. Modifications of these expressive move- 
ments by special localizations of the anxiety, as e. g., in 
the throat, stomach, bladder, uterus, usually accompanied 
by intense somatic sensations in these organs, are the 
ejaculation of grunting sounds more or less animal like, 
touching or pulling at these parts of the body, etc. Also 
the feeling of indefinite physical restlessness combined with 
corresponding motor agitation, ascribed by the patients to 
uncomfortable sensations beyond description and often to 
be observed in complete consciousness, one will be justified 
in tracing them to vague organic feelings, an analogue of 
jactation observed in unconscious states. As is seen in 
these purely somatopsychical motor manifestations, con- 
sciousness need not be summarily excluded. But it behaves 
like a spectator of these processes being enacted in a cer- 
tain measure in deeper regions, sometimes not as a mere 
spectator, in that the affect may develop on the basis of 
perplexity or definite explanatory ideas. Outlines of Psychiatry in Clinical Lectures. 
15 
When you reflect that by means of experiment, a par- 
alytic weakness of the posterior extremities may be pro- 
duced by contusion of internal organs, like the kidneys, 
you will immediately recognize the possibility that states of 
immobility and chiefly of an akinetic sort, may occur from 
the direct effect of pathological organic feelings on motility 
(by short cut). Normal mentality offers analogies. We 
naturally find that patients with nephritic or hepatic colic 
cannot move on account of the pain. Perhaps it is to be 
regarded as similar, when a state of general immobility 
moderate in degree is observed in patients who complain 
of an intolerable crawling sensation in the intestines, or 
when a patient awakens from a state of intense general 
immobility after lasting for months, gives as the reason, 
she had felt a bird in her body, etc. We will find com- 
prehensible in this way the origin of akinetic symptoms 
when the muscles are the seat of the organic feelings. I 
have repeatedly observed cases in which any extensive 
passive movement is painful, it appearing coincidently with 
the most intense feeling of illness and usually with a com- 
plex of melancholic symptoms. 
LECTURE TWENTY-ONE. 
Disorientation the fundamental symptom of every psychosis—Perplexity 
combined with the condition of acute origin—Different kinds of dis- 
orientation and perplexity—Actions thus resulting—Motor 
disorientation and perplexity—Transitivism. 
It might be advantageous if, ere we go farther, we 
become somewhat better acquainted with the most essen- 
tial character of all acute mental diseases by means of our 
instructive case in the engineer K. The psychosis, which 
Mr. K. has had, will more occupy us greatly later, for it 
represents an extremely complicated and heretofore little 
known form of disease. But therefore it is useful for our 16 
C. Wernicke. 
present purpose, for the patient has not only experienced a 
great part of the elementary symptoms, which can be 
derived from our scheme of the identification disorders, but 
is able to graphically describe the effect they have had on 
him. The most general expression we find for this effect 
is disorientation. In disorientation we have to behold the 
real nature of every psychosis. The identification disorders 
considered in our scheme merely represent the means 
nature uses to induce disorientation. There are no insane 
who are not in some way disorientated. If they are not, 
they are not strictly insane. In disorientation exists the 
damages, which the disease process,in greater part unknown, 
causes in the insane. All pathological changes in the con- 
tent of consciousness, which temporarily or permanently 
appear in the insane, may be brought under this concept 
of disorientation. After my previous explanations of our 
scheme this connection between the action and content of 
consciousness, this legitimate consequence of disorientation 
from the pathologically changed action of consciousness can 
only seem natural. The importance of this point of view 
is the more evident, as I might emphasize, that the content 
of consciousness and its changes offer relatively the most 
comprehensible, most evident, most readily estimated mani- 
festations. We will therefore classify the psychoses by the 
changes in content induced by the disease, exactly in the 
same way as we did with the chronic psychoses, and will 
find that we have thus obtained a natural system of class- 
ification complying with all the facts. Corresponding to 
our division of consciousness into three parts of corporality, 
the world and personality, we will encounter the clinical 
necessity of differentiating corresponding kinds of disorien- 
tation and hence use the expressions somatopsychical, alio - 
psychical and autopsychical. Besides we will differentiate 
the disorders of motility occurring in part in the somato- 
psychical, in part in the autopsychical domain as a special 
motor kind of disorientation. When, as in the acute psy- 
choses, the disorientation occurs acutely, it is naturally 
combined with an active affect. An applicable term for 
this is perplexity, which is quite often used by the insane Outlines of Psychiatry in Clinical Lectures 
17 
themselves. Accordinglv we will hereafter have precise 
expressions for the different color of this affect in the 
words somatopsychical, allopsychical, autopsychical and 
motor perplexity. 
Thus Mr. K. spoke wholly spontaneously of the per- 
plexity in which he was for a long time. “He has always 
been surprised, nothing had come of his perplexity.” The 
false sensations particularly, to which the patient has been 
subjected, are the cause. As he has always been essen- 
tially orientated as to his abode and the persons about and 
even presumed a certain orientation as to the combined 
hallucinations by regarding them visions, we see in him 
that the significance of the false sensations really consists, 
as we have previously* regarded it, in the picture of the 
world receiving a pathological accession not corresponding 
to the reality, but still the reality may be recognized as 
such and the allopsychical orientation retained in a certain 
measure. Further we will have to regard this pathological 
accession as disorientating. But the orientation in the 
actual data of the world is not invalidated by the halluci- 
nations. I emphasize this, because we will meet it repeat- 
edly in the acute mental diseases; by false sensations alone 
patients are not robbed of their orientation, even not by 
combined false sensations, in case a state of essential stu- 
pefaction does not exist simultaneously, whereas a high 
degree of allopsychical perplexity may result. One of the 
most instructive examples of this proposition,! have recently 
had opportunity to observe. It was a servant girl W. of 
26, who had had epilepsy since maturity, and about one 
and a half years ago, when eight months pregnant, had a 
short psychosis (lasting six days) after a large number of 
epileptic seizures, since then has been feeble-minded and 
thus repeatedly had shorter or longer attacks of intense 
postepileptic psychoses. She recently had four epileptic 
seizures in one day, the next day had a febrile angina, but 
slept during the evening and a greater part of the night. 
Toward morning she suddenly awoke in a condition I was 
able to observe on my visit six hours later. She presented 
♦See Alienist and Neurologist, vol. xxi, p. 10. 18 
C. Wernicke. 
an extremely affective picture of despair; fire, hell, murder 
threatened her, she would be gotten by the devil, torn in 
pieces, tortured, butchered, broke on the wheel, burned, 
thrown into the water. The world would be destroyed by 
fire, the city burned, the Lord come. She heard all this 
from voices coming from all directions, from which she 
tried to escape by frantic efforts, by the most desperate 
attempts to kill and injure herself. Constant watch- 
ing was necessary to prevent her doing herself harm. At 
the same time she saw heads, forms, flags, soldiers at the 
windows. Still she was perfectly orientated, attentive to 
the medical admonitions, recognized everyone about, took 
medicine readily. With the phonemes there was an intense 
feeling of anxiety in the breast, 4 grains of amyl hydrate 
had an immediate sedative effect; patient stated that the 
terrible talking ceased and thus the annoying feeling of 
anxiety. The attack was relieved without sleep occurring. 
Similar attacks of less intensity still repeatedly occurred 
during the next ten days, followed by the usual condition 
in the interval. In this patient we have learned that bro- 
mides, even in the largest doses, have always failed to 
relieve the psychical symptoms. 
You cannot fail to remember now that condition 1 
formerly termed destruction of individuality, and explained 
by the sejunction process. Here in perfect consciousness 
two groups of incompatible ideas exist, namely the correct 
conception of place and persons on one hand, and on the 
other the fanciful threats regarded as equally real. The 
first, as it seems, cannot cope with the affective color of 
the latter. 
We will become acquainted with states of allopsychical 
disorientation accompanied by active false sensations. In 
view of the facts we have just become acquainted with,we 
are not justified in ascribing disorientation to false sensa- 
tions, but must regard it an independent symptom. 
It is very instructive in this respect, that the same 
patient K., who has now almost recovered from the second 
attack of his trouble, two years prior to the time of his 
first sojourn at the Clinic, he had been in a condition for Outlines of Psychiatry in Clinical Lectures. 
months which consisted in a moderate degree of allopsy- 
chical disorientation and entirely free from false sensations. 
Patient was then surprised at everything he saw and 
experienced, and thought it all had a meaning, as e. g.t 
that food one time was put in his hand, at another put 
beside his bed, a third time was handed over the bed of 
another patient, that the resident physician had once sat 
with his legs crossed, again with them stretched out, one 
time had sat on the edge of the bed, again on a chair. 
Once while a pile of washing was counted in the corridor, 
the patient stood full of astonishment and declared he 
would stay up all night to see what became of the soiled 
linen. The patient was then rendered incapable of any 
coordinated action by the impulse, unnoted by him, of cog- 
itating over every trifle and said: “He did not understand 
anything that happened then, he did not know what he 
should do and not do.” As nutrition suffered, he was 
expressly commanded to eat, and it then improved. 
Besides the states of allopsychical perplexity and allo- 
psychical disorientation, we had to constate in our patient 
autopsychically a confusion of his orientation. He stated 
that during his illness he believed to have acquired insight, 
that in very early childhood he had not been cared for by 
his parents, but in a deaconesses’ asylum, and then later 
returned to his parents. He believed to remember whole 
scenes from his child, which he thus explains. We also 
learned that the idea had become fixed in him, he has to 
suffer for others’ sins, and in transferring this idea to 
others,* his relatives and the resident physician should 
have such a duty. The idea of being a saint and of having 
existed before at different time;, controlled him for a long 
time. Autopsychical orientation has likewise suffered with- 
out the memory of his actual personal experiences being 
lost. For the mental state induced by the opposition of 
these two incompatible series of actual and imaginary facts, 
the patient characteristically used the expression.perplexity. 
We will qualify it by autopsychical. 
That the various pathological sensations and disorders 
*See Alienist and Neurologist, vol, xxiii, p. 133. 20 
C. Wernicke. 
of general feeling, to which the patient has been subjected, 
were suited to produce an affect, is at once evident. We 
will see later, that the most intense affects are combined 
with the changes felt in the body. The affect will be the 
more intense, as more the new feelings differ from the 
familiar physical sensations. Thus we hear the patient 
describe the feeling, as though the brain was soft, as 
though it was enlarged and again contracted, as though the 
head and body were hollow, as though his body was drawn 
in certain directions, as though he was inserted in a mag- 
netic current. The most of these expressions were evi- 
dently comparisons used by him to express his perplexity. 
We may conclude from the thus induced affective mental 
condition, that the attempt made by the patient to take 
his life was due to these feelings. The somatopsychical 
perplexity had evidently increased to despair. As we learn 
the patient had intense feelings of anxiety at the onset of 
his illness. He located the anxiety in the cardiac region 
and also distinguished it perfectly from the feeling of car- 
diac spasm and palpitation, as he did headache from other 
abnormal sensations in the head. This localized anxiety, 
which we wili meet with frequently, may perhaps be 
regarded as a component symptom of somatopsychical 
perplexity. 
We will not go amiss, if we consider a series of con- 
spicuous actions observed during the patient’s severe illness 
to be the result of this prevailing mental state of perplex- 
ity and will try to understand it from this point of view. 
He has occasionally drank from the cuspidor, defecated in 
the sputa cup, on the floor, another time urinated in a 
pitcher, put his clothing on wrong, laid down on the wet 
ground in the yard, etc. The patient now gives partial 
reasons. He presumes he had suddenly become tired,states 
he had been surprised by a sudden desire to urinate or 
defecate, and did not believe the rest. He has forgotten 
many things, as we may readily believe. But we cannot 
doubt from analogy with other patients, that these are the 
actions of perplexity. 
Another series of conspicuous motor manifestations by Outlines of Psychiatry in Clinical Lectures. 
21 
the patient are to be judged from an entirely different 
standpoint. Thus he has actually made gymnastic move- 
ments, for a few days sung several senseless syllables and 
accompanied it by beating time with his arms. He has 
made remarks at the same time by which it is shown that 
he is by no means in the corresponding jovial mood. The 
patient now confirms this. He has sung, although he had 
not felt like it, and now does not know how to explain it. 
But on inquiry we learn that the singing, like the beating 
time with the arms, might be the result of voices, without, 
the patient thinking he is the subject of a direct impulse. 
In the same way he explains the circumstance, that he had 
thrown himself on the ground shortly before admission to 
the Clinic and howled rhythmically with all his might. 
This has been merely a reaction to voices, which had 
“demanded blood.” The patient explains the technical 
term “to demand blood,” which he let slip at this time, by 
the frequent repetition of the word blood by the voices. 
We will later meet with the phenomenon so often that 
some movements are made by the patient in full conscious- 
ness, but are not volitional, the analogue of autochthonic 
ideas, only with the difference that it is a matter of motor 
or objective ideas, so that it is now advisable to employ a 
name for these peculiar phenomena. I generally call them 
pseudospontaneous movements. Explanatory delusions are 
usually combined with them. If our patient simply reports 
the fact, without adding an explanatory delusion, this is due 
to the fact of the patient having been too absorbed in the 
voices he heard at this time. Less precise than with respect 
to the pseudospontaneous movements is the patient’s infor- 
mation regarding certain motor defects, which have been 
observed in him for a long time. The patient has not 
spoken voluntarily (initiative mutism) for weeks and only 
rarely on being questioned (reactive mutism). The balance 
of his conduct does not permit the conclusion, that this is 
due to conscious refusal, for the patient has often been 
seen trying to speak and move his lips without uttering a 
sound, in spite of a perceptible effort. The patient now 
admits this much as certain, that there has been no real 22 
C. Wernicke. 
paralysis of the muscles, which had prevented him from 
speaking, besides he only knows that it was hard for him 
to speak without being able to give any further reason; he 
expressly denies having been forbidden to speak by voices. 
We hear the patient describe hyper (para) kinetic as well 
as akinetic states (disorders of identification) in circum- 
scribed muscular areas; he is able to do this, because he 
remembers them exactly. His mental state during these 
strange and incomprehensible phenomena, he is no longer 
able to describe more exactly, having only very general 
expressions of astonishment for it. Still, as he has per- 
ceived these phenomena in himself during perfect conscious- 
ness—what is not always the case, because these states 
are often attended by clouded sensorium—we may presume 
them due to a corresponding affect, which we will call 
motor perplexity. We thus obtain an expression for a very 
complex mental state, which affects the autopsychical, as 
well as the somatopsychical domain, the first in so far as 
the movements executed in full consciousness are generally 
an emanation of the personality or individuality, the second 
therefore because the involuntary movements must be 
sensed as changes in the body (with respect to its position 
in space). Motor perplexity will generally lead of necessity 
to the formation of explanatory false ideas. If we would 
simply believe the patient’s statements, these would here 
be entirely wanting. But on the contrary 1 must appeal to 
other numerous experiences, which cannot appear accidental, 
that the patient has alluded to in speaking of his autopsy, 
chical disorientation, which we can now connect with the 
stated motor disorders of identification. He has said he has 
believed to have to suffer for others. This “saviour idea,” 
as we will call it, so frequent in the insane, is very com- 
monly united to motor symptoms as an explanatory idea, 
as they have been above described, in that the akinetic 
symptoms are interpreted as a trouble imposed by God, the 
hyperkinetic in that the patient is an instrument of God. 
The affect of perplexity is, as you will have seen from 
the previous remarks, a sort of reactive phenomenon to 
confusion in orientation induced by the stated disorders of Outlines of Psychiatry in Clinical Lectures. 
23 
secondary identification, it is then not to be strictly separ- 
ated from disorientation and frequently combined with it, 
but may occur as you have seen, when a certain orientation 
exists and in this way effects the opposition to reality and 
disease manifestations in the patient. It is found in the 
acute psychoses exclusively; in the chronic it will be sought 
for in vain. Still it occurs in the frequent acute exacerba- 
tions of the chronic psychoses and gives them the stamp of 
acute diseases. Where it is a matter of a very general 
disorientation, the affect may therefore be wanting and thus 
purer the type of disorientation, whether it be in the alio - 
psychical, autopsychical or somatopsychical domain. 
On the other hand, as is readily understood, the affect 
may be wanting, because the capacity for vigorous reaction 
to the acute disorders of identification is very generally 
blunted, i. e., in defect states, as in paretic dementia, pres- 
byophrenia and hebephrenia. Here the absence of per- 
plexity is just as characteristic as is its presence in other 
cases. At this time 1 mention another symptom which is 
frequently combined with perplexity, yet is to be differen- 
tiated from it and is essentially a consequence of autopsy- 
chical disorientation, we will call it transitivism. It depends 
on the fact that the patients, who are devoid of any sense 
of illness, are so changed in their whole thought and feel- 
ing, that the presumption of identifying trains of thought, 
which render us capable of correctly comprehending the 
conduct and behavior of other persons, no longer occurs in 
them. It is preferably their own relatives, whose conduct 
seems strange, peculiar and incomprehensible to the patient 
so that they come to the presumption that they must be 
insane. This symptom is the purest in certain acute dis- 
orders, which have been preceded by a long premonitory 
stage of symptoms not especially psychotic. It culminates 
in the occurrence I have encountered a few times, that the 
patient accompanies his relatives to the office to introduce 
them to the physician as presumable patients. A more 
careful examination of the patient in these cases has 
always shown, me that periods of intense affect combined 
with disorientation were present. C. Wernicke. 
These remarks do not of course fully describe the 
affective state of the acute psychoses, still less can it be 
said that every acute psychosis is accompanied without 
exception by the same affects. But you have at least the 
material indispensable for taking up the theory of illusions 
and the conformity of the content of phonemes. Hence it 
is necessary to return once more to the concept of the 
supraquantivalent idea, 
( To be continued. ) Alienist and Neurologist. 
THE 
VOL. XXIV. ST. LOUIS, FEBRUARY, 1903. No. 1. 
OUTLINES OF PSYCHIATRY IN CLINICAL 
LECTURES. 
DR. C. WERNICKE, 
Professor in Breslau.f 
LECTURE TWENTY-TWO. 
Further as to supraquantivaient ideas—Theory of illusions—Their 
conformable content—Conformable content of false 
sensations generally. 
WE had previously considered as the basis of the 
supraquantivalent idea the frequent repetition, possi- 
bly intentional practice of definite trains of thought, a 
process, which must be recognized as of the greatest influ- 
ence in the education of an individual, for which of late 
the apt expression of preparing the way has been em- 
ployed. This conception requires broadening in so far as 
the preparing the way, will in general go hand in hand 
with an affective coloring of the idea. Thus occupation is 
very especially suited to produce a supraquantivalence of 
certain ideas, but at the same time their affective color is 
expressed, in that momentarily the person’s preponderating 
interest is turned to his occupation. We observed the 
remarkable fact that the susceptibility to certain definite 
perceptions is thus remarkable increased. To select the 
most pertinent example, any disorder or neglect on the 
part of the attendants is at once noticed by the experi- 
enced alienist on his rounds through the hospital, his 
attention and his interest is turned to it without a con- 
scious effort being required; what we call discretion in any 
♦Continued from 
tEnglish by W. Alfred JVlcCorn. ' 2 
Outlines of Psychiatry in Clinical Lectures. 
business affair has this foundation. Likewise the plastic 
artist considers the form, the tailor inspects the attire, the 
shoemaker the boots and unmarried girls notice the ring 
on the fingers of men. The increased excitability for cer- 
tain sensory stimuli is shown to be dependent on the 
increased quantivalence of certain complex psychical pro- 
cesses. If under certain conditions an event of such 
common occurrence as e. g. the apple falls from the tree, 
has attracted the attention of a Newton, it is not an acci- 
dent, but depends on the increased interest, which is due 
in part to certain ideas prevailing at the time, even in an 
event previously indifferent. It is similar with all inven- 
tions and discoveries, in so far as they are combined with 
daily observations. How partial this faculty for the recep- 
tion of certain sensory impressions may be in the preva- 
lence of certain ideas and their affective color is shown by 
the example of the mother, who in deep sleep is oblivious 
to every noise, except the least move on the part of her 
child. We will call this occurrence partial intrapsychical 
hypermetamorphosis. We may consider such an affective 
color and thus induced supraquantivalence of ideas the 
most common basis of illusions. 
The theory of illusions is in great part based on the 
experience from the sense of sight, and the best known 
example is the interpretation of indistinct and vague visual 
impressions in a terrifying, fanciful manner, e. g. the dis- 
tant tree stumps as robbers, the flapping washing as 
ghosts, etc. Evidently these are errors of judgment, i. e. 
clouding of judgment by affects like fear or anxiety. We 
purposely differentiate a distinct and an indistinct percep- 
tion. The clouding of judgment in the latter case may so 
act, as in the examples of visual illusions cited, and the 
affect will have to be considered the cause of the illusions. 
But it is asked, by what process does the affect have this 
influence? As we have seen, we must ascribe to the 
affect the attribute of so changing the normal quantiva- 
lence of ideas that certain ones become supraquantivalent, 
others infraquantivalent in comparison. Supraquantivalent 
ideas have the attribute of being excited peripherally more C. Wernicke. 
3 
readily, the infraquantivalent more difficultly than nor- 
mally. The supraquantivalence of the affective ideas 
of robbers and spirits then in our example pa- 
thologically facilitate secondary identification, the in- 
fraquantivalent interfere with the memory pictures in 
other senses or correcture in the same sense. 
The affect may be of another nature or some associa- 
tion process of an individual sort may cause a supraquan- 
tivalence of ideas, which has exactly the same effect. I 
know of the instance of a young married man, who on a 
business trip to another city made the acquaintance of a 
lady and went with her to a place of amusement. It then 
occurred to him his wife had relatives here and that by a 
combination of improbable, but still possible conditions, she 
might suddenly conclude to visit the city and also come to 
the same' resort. He inspected the company present and 
was soon so firmly convinced of recognizing his wife in a 
lady not far away, that he did not dare insure himself of its 
truth by going nearer, but decided to leave the place. 1 
know of scarcely another example, which could so suitably 
illustrate the preparing influence of single affectively colored 
and thus supraquantivalent ideas for secondary identifica- 
tion in the normal person. If we think the affect increased 
only a little and the mental state thus clouded, and affect- 
ive state, which we may assume in many recent cases 
brought to the Clinic against their will, a series of illusions 
thus become at once comprehensible, which we frequently 
encounter under these conditions. Related supraquantiva- 
lent ideas here are a separation from the relatives and the 
force used in bringing the patient. It is then not strange 
if relatives are believed to be recognized in persons at a 
distance and not distinctly seen, the State’s attorney in the 
physician, a prison in the Clinic. Such illusions are 
frequently met with in many acute mental dis- 
eases. They are characterized in general by their instabil- 
ity and ready correcture. In very severe cases a certain 
confusion, an evident lack of attention may be added, so 
that the condition of an imperfect perception is replaced by 
a defective state of the sensorium. Then, so long as this 4 
Outlines of Psychiatry in Clinical Lectures. 
condition exists, numerous illusions occur, but all of which 
have in common that they change in content according to the 
ordinarily rapid change in the supraquantivalent ideas. De- 
lirious states of the most diverse origin offer pertinent ex- 
amples. It is not accident that the alcoholic deliriant be- 
lieves he is among his companions, at the saloon or en- 
gaged in his daily occupation, thinks he recognizes in the 
physician his cabman or cronie: these illusions correspond 
to his supraquantivalent ideas. Under these conditions a 
good patriot considers the supervisor the Emperor, and if 
the delirum is of an anxious nature, executioner and State’s 
attorney are illusioned. Inaccuracy of perceptions, which 
must favor the occurrence of illusions, will have to be ac- 
cepted as existing so long as the patient is resigned and 
evidently in a dazed condition, so-called (Dammerzutand). 
The same preliminary condition will lead to corresponding 
illusions in states of hysterical, epileptic or so-called ex- 
haustion delirium. 
The occurrence of illusions is harder to understand in 
apparently complete mental possession, attentive condition 
and sufficiently distinct perception. But in this case the 
content of the illusion is usually determined by certain ef- 
fective ideas. Then ordinarily some exact sign may be 
ascertained, which the patient has utilized for his false 
identification. Thus it often occurs that an insane person 
considers the physician, attendant or some other patient a 
near relative, because he discovers some actual similarity, 
e. g. in the facial expression, the form, gait and sound of 
the voice. This mistaking of persons seems to be stable 
and is hard to correct. In a case of stabile mistaking of 
persons cited by Kahlbaum, on the same basis 1 presume, 
the illusion was so fixed that the patient failed to recognize 
his real relative and called him a swindler, an experience 
not so rare among insane after a long detention in the in- 
stitution. It is certainly not an accident, but perhaps the 
longing for the relatives induced by the hospital detention, 
which is the cause of this misconception. Evidently the 
pathological process consists in concept of the relative, pos- 
sibly the brother, being so supraquantivalent that the par- C. Wernicke. 
5 
tial identification of the actually similar tone of voice has 
the same effect as the blunted sensorium in the cases pre- 
viously mentioned. Normally the difference in form, size, 
features and facial expression should prevent the identifica- 
tion. 
Does not here exist, you will ask, a defect, a weakness 
of reproduction in those component ideas belonging to the 
concept of the brother, which relate to the form, size, cast 
of countenance and facial expression? A weakness of the 
cortical function according to Meynert, of criticism as Neu- 
mann calls it? This assumption is entirely superfluous, if 
you will call to mind the attributes of the supraquantiva- 
lent ideas above given. As we have seen in the case of 
hallucinations, the pathological supraquantivalence of ideas 
alone suffices to produce a process of identification, how 
much more must this be the case when an actual, if only 
partial primary identification aids in this inner process! 
Thus is shown the inner fixity of the once acquired con- 
cept, now become supraquantivalent: brother. Hence it can 
not be denied that under certain conditions this weakness 
of reproduction, even a paucity of concrete concepts for cer- 
tain component ideas may be present in an insane person, 
as e. g. in paretics and senile dements, who may declare 
straw to be gold owing to its yellow color, bits of glass dia- 
monds from their hardness and transparency. But then this 
paucity of the concept may be demonstrable elsewhere and 
this is in no way the case in the previously mentioned 
acute insane. You see that in the conception of the illus- 
ions, at which we have arrived, the difference between dis- 
tinct and indistinct sense perceptions, that first seemed so 
important and essential, loses its significance, just as the 
principal difference between illusion and hallucination dis- 
appears. The illusion now seems to us like hallucination, 
whose appearance is facilitated by incidental external con- 
ditions, a conception to which intelligent older authors, like 
Kahlbaum, had come long ago. We will surely admit this 
proposition only for the illusions of the insane and for 
descriptive, practical purposes hold strictly to the 
distinction between illusion and hallucination among 6 
Outlines of Psychiatry in Clinical Lectures. 
the patients of our Clinic. The same reflection will lead us 
to conclude theoretically no other position for the previously 
mentioned hallucinations of evident peripheral origin, i. e. 
in the sense organ, Kahlbaum’s phenacisms, like the hal- 
lucinations from purely central cause. Such phenacisms 
play a great part especially in the matter of taste and 
smell, in that the bad taste from buccal catarrh, the bad 
odor from nasal catarrh is misinterpreted as poison. Here 
also, as we will see later, a supraquantivalent allopsychical 
idea of anxiety is the cardinal cause. 
Prom the conditions mentioned it becomes in a certain 
measure comprehensible why in the frequency of hallucina- 
tions they conform to law, so that phonemes largely pre- 
dominate and often exist alone. This is true particularly 
of many chronic mental diseases. In the acute it is often 
observed that at first only phenomes occur and the acces- 
sion of hallucinations of other senses correspond to a recog- 
nizable aggravation of the symptoms to a certain intensity 
of disease. It is readily understood that in the close con- 
nection between ideation and sensorial speech fields a 
higher degree of irradiation of the stimulation is essential 
to radiate to the projection fields of the other senses, that 
is that which results in hallucinations or word sounds. I 
know that the opinion is common, particularly from the 
writings of Charcot and his pupils, that the process of 
thought takes place in an individually different manner, 
which far surpasses the measure of individual variations 
admitted by me, so that ostensibly many persons think only 
or largely in optical word pictures, others in acoustic, others 
again in the motor. Without contesting this, 1 suppose it is 
for very rare, exceptional cases and therefore not permis- 
sible to use it in the theory of hallucinations. That next 
in frequency phonemes, hallucinations of taste and smell are 
observed, in the acute mental diseases at least, is explained 
by the fact that it is here usually a matter of phenacisms 
and these naturally must occur more readily than the real 
hallucinations. 
Now after I have evolved a definite theory for the 
false sensations of mental diseases, I am in position to C. Wernicke. 
7 
briefly discuss their conformity of content, as I have re- 
peatedly stated, on the basis of a few examples. The law 
here concerned is, that the content of false sensations is 
determined by the prevailing affective state. The affective 
state and consequently supraquantivalent ideas are now the 
most excitable, and not only for the stimuli conducted from 
the sense organs, as we have previously seen, but also for 
the central pathological stimuli associated with the sejunct- 
ion process. To begin with something familiar* I refer to 
the occurrence of a hypochondriacal feeling of well being. 
Accordingly in such cases supraquantivalent ideas occur, 
which give expression to the feeling of well being ,and 
the corresponding phonemes have the content of delusions 
of grandeur. A pathological euphoria we will become ac- 
quainted with in mania. If it here results in hallucinations, 
they are hallucinated ideas of grandeur. Inversely in mel- 
ancholia the affect is one of profound dejection. Accord- 
ingly the content of the phonemes, if present, is usually that 
of micromania. The more frequent visions are in form of 
ideas of dejection. The psychosis of apprehension has been 
repeatedly mentioned in the paranoiac states. The affect of 
anxiety leads in full conformity to law to definite ideas of 
anxiety, which 1 differentiate as autopsychical, allopsychical 
and somatopsychical. Of these the autopsychical are in 
part identical with the micromania of the melancholic, then 
self-accusations or, if in a phonemes, accusations and in- 
sults. The allopsychical ideas of anxiety have the 
content of threats and derogation. Accordingly the patients 
hear they will be killed, tortured, burned, given to wild ani- 
mals, driven out into the snow or naked through the streets, 
etc. It is due to somatopsychical ideas of anxiety, when a 
patient hears her globus interpreted by a voice to be a 
cancer of the larnyx, a bronchial irritation a sure sign of 
consumption, cold extremities the approach of death. 
The most common and general state of affect met 
with in recent cases is that of perplexity, produced by a 
certain moderate degree of disorientation. The most fre- 
quent content of the phonemes corresponds to it. The pa- 
*Alienist and Neurologist, See Vol. XXI, p. 314. 8 
Outlines of Psychiatry in Clinical Lectures. 
tient’s assertions are highly characteristic: Where am 1— 
what shall I do—what is the matter with me—I do not 
know anything, and similar disconnected exclamations are 
heard again and again. If the patients hear libelous 
names and insults, reproaches for imaginary misdeeds, hints 
of events that have never occurred, it is the result of auto- 
psychical perplexity. It is often possible to conclude a 
posteriori such content of the patient’s phonemes from their 
assertions and with perfect certainty, for they permit no 
other interpretation. I cite e. g. the following: I am no 
thief, I have poisoned no one, I have killed no children, etc. 
When the patient’s identity is contested by the voices, it 
leads to assertions like e. g: my name is so and so, I am 
not a princess, am not married, have no children, these be- 
ing evident reactions to the affect of autopsychical per- 
plexity. Allopsychical perplexity is expressed in phonemes 
referring to the place and surroundings. The patients hear 
they are in prison, in heaven, in an enchanted castle, on a 
ship, etc., that the fellow patients are disguised and belong 
to the other sex, or disguised police, that the bed is not an 
ordinary one, the bath tub an instrument of torture, the 
food contains disgusting things or human flesh, etc. 
Phonemes like the following are produced by somatopsy- 
chical perplexity: that the rectum is grown up, the body 
full of feces or changed into a solid mass, the heart has 
stopped, the blood does not circulate, that the patients are 
paralyzed or dead, that the head is separated from the 
body or changed into ap ape’s, that the arms are pulled 
out or many times longer than formerly, or instead of two 
arms there are five, etc. Motor perplexity is very often 
clad in phonemes. This is the most evident when the pa- 
tients hear perfectly contradictory commands, e. g. eat and 
do not eat. Also the command to take a certain position, 
to keep the tongue far protruded, to walk on all fours like 
an animal, are hallucinated assertions of motor perplexity, 
and also when the patients hear that they can not swal- 
low, speak, touch the hand. Finally a great part of the so- 
called impulsive actions, but in reality caused by phonemes, 
have to be explained in this way. The patients hear the C. Wernicke. 
9 
command to escape, jump out of the window, throw them 
selves into the water, hang themselves, throw themselves 
on their head, pull out their tongue, mutilate the genitals, 
gouge out the eyes. 
1 limit myself to these examples, which 1 believe are 
sufficient evidence to show the dependence of the content 
of phonemes on the affects most frequent in acute mental 
diseases. 1 would only have to add, that in a certain re- 
spect the delusion of relativity depends on the affect state 
and refer as to this to my remarks in the thirteenth 
lecture. If these chiefly relate to the delusion of relativ- 
ity in the baroniac states, it is at once comprehensible that 
in the acute psychosis the delusion of relativity has a still 
greater affective color. It is especially the satisfaction of 
the demands of Nature in taking food, relieving the bowels 
and bladder, which in the acute psychoses cause the occur- 
rence of phonemes with the content of the delusion of rel- 
ativity, and especially frequent of disorientating phonemes, 
which are clad in the tone of voice of the person chiefly 
concerned, then of the attendants or physician. Taunts 
and twitting remarks naturally predominate, as e. g. : “now 
he eats again,” or: “he can eat well, but not work.” 
It is very probable that not only the phonemes, but all 
hallucinations show the conformable dependence on the pre- 
vailing affect which we have become acquainted with in 
the phonemes. Still our experience greatly needs comple- 
tion. It is the best known of visions that their content de- 
pends on the prevailing affect and that applies especially to 
melancholia and the psychosis of apprehension. Corres- 
ponding to the prevailing dejection corpses, coffins, uncanny 
black forms, funerals or in more fantastically colored cases 
the destruction of relatives by falling buildings, by flood, by 
railway accident, etc., are hallucinated; usually at least in 
more shadowy form with the support of this standpoint it is 
a matter of visions. That the visions of the ecstatic cor- 
responding to their religious feeling of happiness, relate to 
heaven, and that it is here often more a matter of dream- 
like hallucinations than of visions, is readily comprehen- 
sible after what has been said. 10 
Outlines of Psychiatry in Clinical Lectures. 
LECTURE TWENTY-THREE. 
Presentation of a Case of Psychosis with Apprehension. Form of the Dis- 
ease, Course, Diagnosis, Prognosis, Treatment. Separation 
from the Neuroses with Apprehension. An Example of 
Psychosis with Hypochondriacal Apprehension. 
The patient Sch., whom we have here, has objected to 
coming to the auditorium. He looks about anxiously, 
slowly comes nearer, but then greets me as an acquaint- 
ance. We have a man of 55, large, vigorous physique, in a 
state of lowered nutrition, with somewhat cyanotic color of 
the face and hands, cold extremities, anxious in manner and 
facial expression. A low moan is repeated rhythmically and 
now and then interrupts his talk, while he shows a great 
desire to speak. He looks grieved when 1 interrupt him to 
make explanations. He answers correctly my questions as 
to age, domestic relations, his home, business, but it is no- 
ticeable that his affects make it hard for him to concen- 
trate himself, that he pauses, when he looks about vacant- 
ly, and that therefore the answer to simple questions, 
which otherwise is prompt, often requires a longer time. 
Patient repeatedly admits that it is hard for him to collect 
himself. The impression we gain of the affect controlling 
the patient is that of confusion, anxiety and perplexity. 
That these states of affect render difficult a coordinated 
train of thought has long been known and repeatedly dem- 
onstrated. On inquiry we learn that the patient complains 
of constant anxiety. Seat of the anxiety in his heart: “it 
will crush him”. He can not breathe and therefore has 
not slept at night. Consequently he wishes me to exam- 
ine him and prepares to undress in his anxious, hasty way. 
To the question why he is so anxious, he says the fear of 
being beheaded; he has also heard he shall count fifty 
daily, he is presumed to eat biscuits which have been in an 
expectoration cup of another patient. On inquiry we hear 
that the other patients, who are in the same room with C. Wernicke. 
11 
him, have made these assertions. The patient is well 
orientated and knows he is at the Clinic for insane. Still 
he does not thoroughly comprehend the present situation, so 
it might be that the patient has previously had somewhat 
limited conceptions, as we frequently find in the country 
people of this region. He recognizes me, recognizes the 
audience to be students and thinks I give them instruction, 
but still believes the gentlemen will all become preachers 
like his son, who is a student of theology and accom- 
panied him to the Clinic. In the ward the patient has 
claimed they will cut off his head, he will be taken to the 
morgue where the corpses are. Besides it is not merely 
the fear of the threats which control the patient, we hear 
many complaints as to the fate of his family. He believes 
he has lost all he has; his son will be unable to study any 
longer. He has heard the voice of his little son say: “we 
have had nothing fit to eat for three weeks,” the patient 
has also seen his son standing before him with supplicating 
gestures. Patient believes his family must die of hunger. 
The children are all sick, his son, the student, has been re- 
fused by a life insurance company owing to a heart 
trouble. He is to blame, he has ruined himself by an im- 
moral life and secret sins in his youth. He has been too 
corrupt. He has also injured himself by chewing too much 
tobacco. Patient tells of an assault in which he recognized 
one of the assailants and has made a complaint. He then 
probably perjured himself, for it had been in the night and 
he could not have seen plainly enough. Formerly, when 
the anxiety was still greater, the patient had complained 
that both his younger children had been poisoned, had taken 
the life of his wife. At this time the patient, who has a 
hernia, had eaten poorly and claimed he had pains in his 
abdomen from eating. 
Except the hernia no organic disease is to be found, 
he looks in no way older, but younger than he is. The 
patient has now been at the Clinic something over a 
month and sick for about three months before. The ex- 
ternal cause of his disease was said to be that the patient, 
owner of a blacksmith shop and a farm adjoining, sold this 12 
Outlines of Psychiatry in Clinical Lectures. 
property and the shop to put himself at rest. Although the 
business was profitable and went smoothly, the patient 
gradually got the idea he had ruined his family and became 
poor. Anxiety, self-reproaches, which referred to the fan- 
cied perjury and the idea he is a great sinner and 
persecuted by Satan, were gradually associated. These ideas 
of autopsychical anxiety existed alone in the early part of 
the disease, and shortly before admission those of the fan- 
ciful menace were added, simultaneously such an aggrava- 
tion of the anxious restlessness (anxious motor impulse) 
was noticeable that commitment of the patient to an insane 
hospital was unavoidable. Here the patient seems to have 
attained the crisis of his disease and now to have passed 
it. This is indicated by the subsidence of the ideas of 
somatopsychical anxiety. Besides a manifestation, the pa- 
tient’s rhythmical moaning, which is now only intimated, was 
much more pronounced in the early part of his sojourn and 
at times was increased to a monotonous repetition of one 
and the same phrase (I poor sinner). This was sometimes 
accompanied by rhythmical movements of the arms. The 
anxiety seems to have reached its highest point about this 
time. Nutrition was impaired only at the time the ideas 
of somatopsychical anxiety occurred, sleep must usually be 
induced by hypnotics. His weight fell from 78 kg. at the 
time of his admission to 72 kg., its present condition, while 
the amount of food taken has usually been sufficient. 
With regard to the prognosis we are justified in calling 
it favorable on the basis of the course and other data. The 
course is seen to be of acute onset, then an exaggeration 
of the symptoms for a period of about a week, during which 
parakinetic and hyperkinetic symptoms in form of verbiger- 
ation and rhythmical movements of the arms occurred. This 
period corresponded to the height of the anxiety and the oc- 
currence of ideas of somatopsychical anxiety. Since then 
the independent motor as well as the hypochondriacal symp- 
toms have ceased and the anxiety lessened in intensity. 
Delusions of relativity and disorientating phonemes of cor- 
responding content are not intense. Thus the intensity of 
the fundamental phenomenon, the anxiety, accords with the C. Wernicke. 
13 
extent of the symptoms; the disappearance of the symp- 
toms is to be expected in similar order.* 
The form of disease described is typical of a large series 
of analogous cases, only a few slight deviations must be ex- 
cepted, which prevent the case from appearing perfectly pure. 
Perhaps it is a matter of the peculiarity of the individual, as 
I intimated. In general it can not be denied that the elemen- 
tary symptom of anxiety affords the exclusive basis of a 
type of disease, which in many instances presents no other 
symptoms than those to be traced to the anxiety. We can 
put all these cases under the term psychosis with apprehen- 
sion. The fundamental symptom is the anxiety, which is 
most often located in the breast, especially in the heart and 
epigastrium, next the in head, then in the whole body and 
always of a fluctuating character, intermitting at the onset 
or decline of the disease. This anxiety induces certain 
ideas, which therefore deserve the name of ideas of anxiety. 
They are so shaded that the ideas of autopsychical anx- 
iety correspond to the lower intensity of the anxiety, the 
allopsychical and somatopsychical to the greater intensity. 
The somatopsychical may sometimes be absent or, as in 
this case, appear only at the time of the crisis of the dis- 
ease. At the onset and the decline of the disease ideas of 
autopsychical anxiety are usually alone present. In many 
cases it consists wholly of ideas, far more often the ideas 
are clad in phonemes. At the height of the anxiety hallu- 
cinations of the other senses may occasionally occur and in 
certain very acute cases, as e. g. in the attacks of anxiety 
described of epileptics, combined hallucinations in all the 
senses. The condition is so frequent that usually only 
ideas of autopsychical anxiety of moderate intensity exist, 
or a combination of ideas of autopsychical and allopsychical 
anxiety, and phonemes only occur at times of increased 
anxiety. The allopsychical orientation is retained, the auto- 
psychical usually altered permanently in the way of micro- 
mania. The perplexity may be extended to the allopsychi- 
cal domain. Indications of delusions of relativity are often 
*Three months atter the demonstration the patient was actually well and has been so 
for two years. 14 
Outlines of Psychiatry in Clinical Lectures. 
met with at times of intense anxiety, disorientating 
phonemes of this content also occur. The content of the 
ideas of autopsychical anxiety and corresponding phonemes 
is solicitude about the relatives, the financial condition, in- 
jury to personal honor, micromania, self-accusations, conse- 
quently insulting phonemes. The content of the ideas of 
allopsychical anxiety is usually that of menace to life or 
honor, abuses, etc. The delusions of relativity behave in 
the same way. Of the hallucinations associated with es- 
pecially intense affect, those of taste and smell are to be 
mentioned in particular, because they are usually regarded 
as the effects of poison and induce a temporary refusal 
of food. 
Of etiological factors, alcoholism, epilepsy, the climac- 
teric and senility seem to be closely related to the psycho- 
sis with apprehension. 
With respect to the course of the psychosis, it may 
last from a week to several months. The shortest course 
is observed in abortive cases in epileptics and alcoholics. 
It sometimes happens that delirium tremens is replaced by 
an acute psychosis with apprehension of a very affective 
stamp with pronounced ideas of autopsychical anxiety. The 
psychosis is then of correspondingly short duration and ac- 
companied by tremor and the symptoms on the part of the 
projection system to be discussed later. The psychosis 
with apprehension quite often occurs symptomatically, es- 
pecially in heart defect with deranged compensation, when 
its course in point of time generally depends on this 
condition. 
A real paranoiac stage does not generally occur, except 
consciousness of disease may be wanting for a long time. 
The patient’s motor state is generally determined 
purely psychologically by the affect of the content of the 
ideas of anxiety and hallucinations. The majority of pa- 
tients can usually be treated in bed, still the exaggeration 
of the anxiety causes a certain motor restlessness, chiefly 
expressive movements of anxiety like crying, sobbing, 
wringing the hands, kneeling, praying, according to the indi- 
viduality. In many cases tremor, grinding the teeth, pro- C. Wernicke. 
15 
fuse perspiration occur. If the anxiety is still further in- 
creased the patients get out of bed, walk about restlessly, 
try to get away. Motor manifestations not psychologically 
induced, or at least on the boundary of motor symptoms, 
are generally rhythmical moaning or swaying of the trunk, 
most often the two together, finally the monotonous, if not 
rhythmical, yet repeated movements of the hands, pulling at 
the bedding or clothing, rubbing the hands together, etc. 
The tendency to suicide is almost always pronounced, as 
well as the desire to die is often manifested in expressions 
like: “Put an end to me. Strike me dead.” At the 
crisis of the disease the motor symptoms just described or 
those still more pronounced readily occur, particularly a 
parakinetic condition by rhythmical movements and verbig- 
eration. On the other hand a state of allopsychical disor- 
ientation and an exaggeration of the sensorial symptoms to 
fear of everyone and blind defense. 
Melancholia agitata so-called deserves to be expressly 
mentioned as a special form of the psychosis with appre- 
hension. Motor restlessness is constantly very pronounced, 
the movements are not wholly, if largely of psychological 
motive,.they are in part, as above described, on the bound- 
ary of real motor disorder. But it is especially striking, 
that the increased production of ideas of anxiety may lead 
to impulsive talking and flight of ideas, symptoms, which 
we will meet later in an entirely different form of disease, 
but whose sensorial derivation here is not to be mistaken. 
It seems to be peculiar to these cases of agitated melan- 
cholia that the ideas of autopsychical anxiety predominate 
largely, if the allopsychical are never entirely absent. 
Diagnostically it is to be first observed, that the dis- 
ease often develops further and only forms the initial stage 
of a more complicated form of disease. This further devel- 
opment occurs in two ways, namely in form of a complex 
motor psychosis, usually characterized by the addition of 
akinetic symptoms, and in form of a more diffuse sensorial 
psychosis with disorientation. In the latter respect a sus- 
picion must always arise, whether disorientating phonemes 
and delusions of relativity are more than incidental factors 
in the disease type. 16 
Outlines of Psychiatry in Clinical Lectures. 
The further development may be effected very quickly, 
so that the most acute forms of disease like those of the 
transitory psychoses so-called result. 
For the diagnosis from affective melancholia the evi- 
dence of ideas of allopsychical anxiety or delusions of 
relativity is decisive. From acute hallucinosis the 
diagnosis is generally easy. The dominating symptoms 
of anxiety, according to the patient’s statements, are 
objectively conspicuous, the frequently observed depend- 
ence of the phonemes on the variations in the anx- 
iety, are most characteristic. But it is equally character- 
istic, that acute hallucinosis very early develops a parano- 
iac stage, which is not true of simple psychosis with appre- 
hension. The retained allopsychical orientation distinguishes 
the simple psychosis with apprehension from delirium 
tremens tinged with fear. Likewise general sensorial 
psychoses are usually accompanied by disorientation. In 
many instances therefore the psychosis with apprehension 
is not to be differentiated from progressive paresis, because 
from the clinical standpoint the occurrence of a paretic 
psychosis with apprehension must be admitted. During 
the affect it is often hard to establish the disorder of mem- 
ory, judgment and the ability to attend, almost always de- 
monstrable in paresis, on the other hand the possibility ex- 
ists that the symptoms in the projection system decisive 
for paresis—or alcoholism—are absent and first appear later 
in the course. 
Cases of disease are very often met with, which may 
be called borderland cases or mixed cases of psychosis with 
apprehension and affective melancholia. They are character- 
ized by the fact, that neither one or the other form of dis- 
ease can be demonstrated pure or complete. From the ex- 
ternal appearance the picture of affective melancholia usual- 
ly predominates, especially because the fluctuations in the 
anxiety are less pronounced and a more continuous, sta- 
tionary type of disease prevails. The subjective insuffi- 
ciency of affective melancholia is often wanting, while pro- 
nounced micromania, self-accusations and other ideas of au- 
topsychical anxiety are present. The prevailing affect is C. Wernicke. 
17 
that of misery, but also a localized anxiety. The mani- 
festations of anxiety are usually limited to the simplest ex- 
pressive movements, like those of crying, sporadic outbreaks 
of despair, while a motor restlessness is generally wanting. 
Ideas of allopsychical anxiety are almost always demon- 
strable, but they are sporadic, recede greatly in their im- 
portance and must often be sought for. Likewise, wholly 
sporadic delusions of relativity occur. The idea of misery 
prevailing among those of anxiety are often confined to a 
circumscribed group of ideas as in pure melancholia. The 
phonemes are subordinate factors. 
Thus the quite frequent form of disease is sufficiently 
characterized in both ways. It seems to occur preferably in 
very young persons and in old age. The diagnosis is there- 
fore not unimportant, because the prognosis of this disease 
is not only to be made with more certainty than in the 
psychosis with apprehension, but it is by far more favor- 
able. The cases of the kind I have known have all term- 
inated favorably. 
The prognosis of the psychosis with apprehension is to 
be called favorable, for in by far the greater majority of the 
cases above described recovery has occurred. This favor- 
able opinion is modified by the difficulty in making a cer- 
tain diagnosis until a greater part of the course of the dis- 
ease is past. When, as in the case presented, the crisis 
of the disease is past, it may be assumed with some cer- 
tainty that a transformation of the disease into one more 
complicated will not occur, and in this expectation one is 
sometimes deceived, for after a stage of apparent conva- 
lescence, a further development of the psychosis into a 
progressive course may occur. So it is e. g. in a case of 
senile psychosis with apprehension in a woman of 73, 
whom 1 could present after a course of \ J/2 years, as a typ- 
ical example of a chronic case with hypochondriacal de- 
lusions of persecution in the stage of allopsychical d?sor- 
entation*. In this case the form of disease was unfavor- 
ably colored by numerous disorientating phonemes and de- 
lusions of relativity. 
*See case 1 in “ Kratikenvorstcllunzen dtr Brestaucr Psychiatr. Klinik,” Heft 1. 18 
Outlines of Psychiatry in Clinical Lectures. 
The treatment of the psychosis with apprehension has 
the special task of combating the symptom of anxiety. 
To simply bear intense anxiety for a long period can not 
be expected of any patient, just as little' as the analogous 
symptoms of pain. In general extract of opium, in doses of 
to 2 dcgr. subcutaneously, is a reliable remedy. Next a 
combination of hyoscine with morphine, and of the first 
half of as many milligrams as centigrams of the latter, is of 
value. The dose may be daily increased from % mgr: Y* 
cgr. to x/i mgr. : 1 cgr. In the paroxysms of anxiety in 
epileptics, a hypnotic dose of amyl hydrate internally, or by 
clyster, is preferable. The further treatment of the psycho- 
sis with apprehension presents no other problems than that 
of psychosis in general, and therefore I refer you to my re- 
marks on this subject at the conclusion of these lecturest. 
No other province of mental disease has so many 
points in common with the functional neuroses as that 
which has just received our consideration. As frequent as 
the psychoses with apprehension are, it is incontestible 
that the states of anxiety, which come within the do- 
main of the neuroses, are generally far more fre- 
quent. The question then arises: are there certain criter- 
ia for differentiating a neurosis with apprehension from a 
psychosis with the same affect? This question is of great 
practical importance, for with the psychosis with apprehen- 
sion it is the physician’s duty to assure the patient’s 
safety by commitment to an insane hospital, even against 
the patient’s will. Such interference with the personal 
liberty of a neighbor would by no means be tolerated in a 
mere neurosis. Fortunately the type of disease above de- 
scribed presents in its complex of symptoms such certain 
signs readily recognized, that the positive diagnosis of a 
psychosis with apprehension is easy and thus a doubt as 
to the correct method of procedure is obviated. Still un- 
questionably there are here, as everywhere in Nature, bor- 
derland cases, in which doubts as to the propriety of such 
a vigorous measure are justified. It will then be the phy- 
ffhe reader finds examples of psychosis with apprehension In cases 3, 8, 9 and 12 
in the first part and 5, 21, 22 and 23 in the second part of the “Krankenvorstellungen ausder 
psychiatrischen Klinik in Breslau,” Breslau 1899. C. IVernicke. 
19 
sician’s duty to provide for the greatest possible security 
and supervision of the patient in private. There is no 
better means for this than bed treatment, carried out 
strictly. But then, as above stated, the symptom of anx- 
iety itself will have to be treated. The patient’s welfare 
is always paramount to all other considerations and there- 
fore the practical consequences, which the patient derives 
from his feeling of anxiety and the associated ideas of mis- 
ery and anxiety on his action must be clearly kept in 
mind. Always remember that a single symptom, like anx- 
iety, never suffices to diagnose a psychosis, but that on the 
other hand to the patient’s actions equally as much value 
at least is always to be ascribed as to what he says. 
When suicidal attempts occur the patient’s safety, by com- 
mitment to an insane hospital, is unconditionally demanded 
in these borderland cases. 
1 have begun the description of special disease types 
with the psychoses with apprehension, because on the one 
hand they are cases relatively easy to understand, on the 
other their points of contact with many other acute psycho- 
ses are so numerous, that they soon lead us into the midst 
of our practical problems. 1 scarcely need say that the 
practical knowledge of mental diseases has nothing to do 
with theoretical hypotheses. Therefore our method of 
demonstration will be essentially governed by the purpose 
of instruction and this subordinated to the practical re- 
quirements. The patient I now present belongs in this 
practical sense to the psychosis with apprehension, but, as 
will soon be seen, brings us to the subject of our next 
lecture. 
The working woman L., 69, as is seen, a white haired 
woman, walking somewhat stooped with depressed slightly 
anxious facial expression and corresponding manner. She 
answers questions promptly, if in a somewhat feeble voice. 
She tells us her birthday, the date of her marriage, how 
long she was married, the date of her husband’s death and 
his illness, gives the names of her children, tells us of her 
only living daughter and her marriage, speaks of her grand- 
children. We learn from her all the prior history of her dis- 20 
Outlines of Psvchiatiy in Clinical Lectures. 
ease. In the spring of 1896 she became ill from a tumor 
in the body, which was then operated on. She then spent 
eleven weeks in the hospital, was very weak afterward, 
but well otherwise. In November she had the shingles and 
could sleep hardly at all for three weeks. Early in Decem- 
ber the present trouble appeared. The time of her stay at 
the Clinic—since February 24th of this year—she states 
nearly correct, shows she is thoroughly orientated as to the 
purpose of the institution and her fellow patients, knows 
that the gentlemen present are students who visit the 
Clinic. I present her to speak of her disease. What is 
her disease? She can eat nothing because her throat is 
grown up or, as she corrects herself, only a very little passes 
through. The tongue has grown to the roof of the mouth. 
She feels with her hand and demonstrates that the upper 
surface of the tongue touches the roof of the mouth. Be- 
sides she constantly has the taste of pitch in her mouth 
and what she eats has no taste. What she swallows with 
difficulty she feels sticking in her throat. It accumulates 
in the stomach and causes a feeling of tension. Formerly 
defecation has not been possible, and now only occurs through 
artificial means and insufficiently. I ask if she is not some- 
what better, but she replies in the negative. Still I must 
remark that the patient has actually improved. She was 
formerly so weak and infirm, that she replied in a very low, 
feeble voice and a demonstration like to-day would have 
been impossible. Owing to her feeling of severe illness 
she then did not speak of herself at all, while she does 
now occasionally, and took no part in what went on about 
her, while she now shows some interest. She then stated 
that her esophagus was completely grown up and had to be 
fed by force, while she now takes some food spontaneously. 
We have further learned from her daughter, that she pre- 
viously complained that she could not get her breath. 
What her disease is the patient is unable to say defi- 
nitely, still it is something very bad, entirely hopeless. She 
has formerly said it is the pest and that she feared infect- 
ing others by contact. In this respect she has surely im- 
proved, for she does not think so now. C. Wernicke. 
21 
If we ask the patient how she likes her treatment here 
she replies: good, she is not worthy of it. What has she 
to reproach herself for? She is bad and sinful through and 
through, has tried to take her life, is a fright, a spectacle 
before persons and deserves to be thrown out. The other 
patients cry on her account. She has brought her sickness 
on herself by not eating, she has not treated her mother 
properly in her last illness. As a further sign of fanciful 
micromania I will still mention, that the patient to 
go into the reception room, because the other patients will 
not look at her, and has said, when preparations for photo- 
graphing were being made, the photographer would be so 
shocked by her appearance that he would fall dead. Fur- 
ther the patient is convinced she cannot die, because she 
is too bad. She now expresses the desire to die and be- 
fore her admission tried to strangle herself twice, because 
she could not bear it so. The patient believes her grand- 
children are very sick, perhaps dead, and she formerly ex- 
pressed the idea they would die on her account. As she 
then claimed to be to blame for all the misfortunes she 
heard of, e. g., when an acquaintance burned his hand. 
She likewise expressed the fear she would not be admitted 
to any hospital, because she is too bad. Although the pa- 
tient gives systematic information and presents no external 
signs of anxiety, she still admits on inquiry to have anxiety 
constantly. Where is the anxiety located? In the head. The 
anxiety is distinctly differentiated from the anxious feeling 
in the epigastrium, according to prior statements the anx- 
iety was sometimes located in the breast. With respect to 
the patient’s conduct on the ward, it is stated that she has 
always been affable and trusty. She has always been tidy 
and only occasionally disturbed; owing to her delusions she 
pulls at her anus or handles her excrement. 
Other symptoms have not been found in the patient. 
Her delusions have always been confined to the pathologi- 
cal ideas described, to her body and her personality, and her 
conduct thus determined. With respect to the conception 
of the disease a review of its course is very instructive. 
It is unquestionably shown, that from the onset the present 22 
Outlines of Psychiatry in Clinical Lectures. 
hypochondriacal troubles existed and that they gradually 
led to the patient’s extreme emaciation—her weight on ad- 
mission was 31 kg., hence the necessity of her admission 
to the Clinic. 
The other pathological ideas first appeared at a certain 
height of the disease, after the isolated hypochondriacal 
complaints had existed for weeks. A test of perception and 
attention showed a normal condition. The information we 
have gotten from the patient has always been given in 
concise answers to the questions asked her. THE 
Alienist and Neurologist 
VOL. XXIV. 
ST. LOUIS, MAY, 1903. 
No. 2. 
OUTLINES OF PSYCHIATRY IN CLINICAL 
LECTURES.* 
B, dr. c. Wernicke, 
Professor in Breslai^.f 
LECTURE TWENTY-FOUR. 
Intestinal, Ascending and Diffuse Somatopsychoses—Hypochondriacal Reflex 
Psychoses—Severe Hypochondriacal Psychosis in an Inebriate—Ex- 
ample of a Paretic Somatopsychosis—Form of Disease 
and Actions of Somatopsychical Perplexity— 
Terminations—Review of the Hypo- 
chondriacal Symptoms. 
IN the patient recently presented you have an example 
of those cases occurring frequently, which deserve the 
name of psychosis with hypochondriacal apprehension. As is 
seen it is a matter of circumscribed intestinal somatopsy- 
chosis, depending on abnormal physical sensations in the 
digestive tract, which quickly lead to disorientation in a cir- 
cumscribed and intestinal domain of the consciousness of 
the body. The attending feeling of severe illness is read- 
ily comprehensible as a sequence of the disorder of soma- 
topsychical identification. Our patient called her mental 
state anxiety, but more often, in accordance with the para- 
mount change in content, the patient says the affect is not 
real anxiety, but something different, especially those pa- 
tients who are in possession of better expressions owing to 
their education. It is evidently a matter of that affect we 
have become acquainted with as physical or somatopsychical 
* Continued from Alienist and Neurologist, Vol. xxxiv. No, 1, 
t English by W. Alfred McCorn. 2 
Outlines of Psychiatry in Clinical Lectures. 
perplexity. Then further, an anxiety occurring in paroxysms, 
differentiated as something special, new. 
Circumscribed intestinal hypochondria is preferably lo- 
cated in the vicinity ©f the two terminals of the digestive tract, 
accordingly as the difficulty in swallowing exists at one time,re- 
garded in its broadest sense, so that the whole act of con- 
veying food to the stomach is meant; again difficulty in de- 
fecation is the most prominent of the symptoms. In a 
case of the latter sort a rectal catarrh, which was main- 
tained by hemorrhoids, could be ascertained to be the basis 
of the hypochondriacal ideas, and likewise a globus, which 
had existed previously, might in female patients often be 
the starting point of the other form, traceable to the sub- 
jective difficulty in swallowing. 
As is perceived from such examples, the interpretation 
is unquestionable that it is a matter of a disorder of psycho - 
sensorial identification in the domain of organic feeling, but 
hard and often not to be established whether hyperes- 
thesia, paresthesia or anesthesia exists. 
The two different initial localizations lead to the same 
result at a certain stage of development, to the feeling of 
being stuffed, in one mode of origin that the food, either 
swallowed with difficulty or artificially introduced, accumu- 
lates in the stomach, in the other, that masses of feces 
dam up from below, even to the throat eventually. The 
most common and important consequence of these patho- 
logical sensations is refusal of food, which in cases of the 
kind almost always renders forced feeding by the stomach 
tube necessary. A feeling of intense misery is always 
present, wholly comprehensible from the prevailing feeling 
of severe physical illness. Thus the judgment of the fu- 
ture is influenced: the patients always believe they are ab- 
solutely hopeless and lost. The real ideas of anxiety in 
the pure cases of the kind are confined to the autopsy- 
chical domain and within it are limited to the patients 
blaming themselves for having produced or aggravated their 
disease by neglect of medical advice or orders. In the case 
of an unmarried woman of 60, who became acutely ill with 
this form of intestinal somatopsychosis with persistent re- C. Wernicke. 
fusal of food, after a prolonged period of nursing, combined 
with depressive affects. The abnormal sensation in the 
throat ceased after the disease existed about six months, 
but the feeling of misery and the ideas of autopsychical 
anxiety of having no bowel movement, and the disease fin- 
ally terminated fatally. 
With regard to the motor condition in this disease, it is 
wholly of psychological origin in the pure cases. Perhaps it 
is due to individual variation, that in one patient more of an 
agitated character, outbreaks of crying and despair, lamen- 
tations, wringing the hands is more observed, in another a 
loss in motility to a moderate degree, as we find it explain- 
able by the feeling of severe illness. This condition can 
either exist in like manner during the whole course of the 
disease, one condition replace the other, or the agitation 
corresponds to one or more of the highest points of the 
disease curve. Inversely an extreme loss in motility, in 
other words an intrapsychical (psychosensory) akinesis may 
correspond to an increase in the extent of the symptoms, 
and 1 have observed this, e. g., in a case of ascending in- 
testinal somatopsychosis. Here then the akinesis was the 
severer symptom, as it was then to be derived accordingly 
from an increase in the feeling of illness, for the patient 
was untidy and claimed to be unable to stand, walk or 
talk. These functions were actually retained, as might be 
established by incidental reactions. 
It was a matter of a woman of 57, who for years had 
a hard struggle for existence and then became ill with the 
sensation of closure of the rectum. Six months later, at 
the time of the crisis of her disease, she was filled with 
masses of feces, could no longer breath, could not move. 
While at the onset of her illness she again manifested in 
despairing restlessness her fear of having to starve, after an 
intercurrent influenza she passed into the state of profound 
exhaustion described, in which she complained of the slow- 
ness and difficulty in thinking. An infiltration of both up- 
per lobes seemed to make the prognosis absolutely hope- 
less, nevertheless, after remaining several weeks in the con- 
dition described, the patient convalesced and in about a 4 
Outlines of Psychiatry in Clinical Lectures. 
year could be discharged improved to family care. The 
disease curve in this case may be considered as purely ex- 
tensive and the akinesis corresponded to the highest point 
of the curve. The case was interesting in that the cardiac 
oppression was always stated to be a separate symptom, 
and that ideas of autopsychical anxiety in form of self- 
accusations occurred only temporarily and by intimation. 
More plainly than in the preceding case is the ascend- 
ing tendency of a circumscribed hypochondria confined to 
the genital organs, shown in the following, which I have 
presented a few semesters ago. It is a Jewish girl of 23, 
who previously had several attacks of a psychosis, first of 
a melancholic nature, then more of a maniacal, and whose 
sister had twice been insane. She had lived in her broth- 
ers family and most devotedly cared for his seriously ill 
child. At the onset of her illness she complained of the 
feeling of a hard body in the genitals and was therefore 
treated by a gynecologist. It was accompanied with burning, 
tenesmus of the bladder and desire to urinate while men- 
struation was suppressed. An objective condition could not 
be constated. When the child died about two months later 
the patient began to take the hardest work on herself, 
nevertheless, she soon claimed she was worthless, could not 
work, was in the way and a burden on her brother. About two 
months later she attempted suicide by chloroform and was 
unconscious for several hours. A thwarted attempt to jump 
into the water about three months later was the cause for 
sending her to the Clinic, the patient having worked hard 
until the last day from micromania. In the last two weeks 
outside and the first month of her stay at the Clinic, her 
physical troubles increased to a very desperate condition. 
Patient stated that in consequence of insufficient defecation 
food collected in her and had been changed into a solid 
mass—not feces, as she expressly stated. This hard mass 
is forced into all parts of the body, the whole body is de- 
formed by it, has become firm and hard, only the skin is 
still natural. Patient is convinced of this by the internal 
feeling of weight and she feels herself with her hands. 
The body seems to her dead and insensible, and as if no C. Wernicke. 
5 
blood flowed in it, although the patient feels her pulse 
and hears her heart beat. This numbness affects the sense 
organs also: she can hear with her ears, but her eyes are 
fixed in her head, she cannot move them or open the lids. 
When eye movements were executed at the examination, 
she maintained this is not true and she must turn her 
head instead. She is in doubt whether she can smell, feel, 
taste; she tries it with milk and then answers affirma- 
tively. She can swallow and move the tongue. Patient 
persistently refused food at this time and had to be fed 
with a tube. She claimed that defecation was insufficient, 
even when injections or cathartics, which she takes wil- 
lingly, have acted and she has felt relieved for the time. 
The feeling of the severest illness, absolute hopelessness 
in regard to her physical condition and a corresponding de- 
pression constantly exist. Still anxiety was complained of 
only temporarily at times of extreme excitement and des- 
pair, the feeling of anxiety being located in the breast. 
With respect to the patient’s motor condition, out- 
bursts of despair ceased owing to progressive loss of 
strength. The delusion existed she had sinned by eating 
too much, she is eternally lost, deserves the severest pun- 
ishment, which she longs for, e. g., like being burned. Her 
detention at the Clinic—where she must of necessity be 
kept under observation—she considers deserved, if too mild 
punishment. Further her intellect was intact, orientation 
completely retained in spite of physical weakness, no re- 
tardation, hallucinations or delusion of relativity. With 
constant loss in weight, death occurred after nine month’s 
stay at the Clinic. 
Cases in which the pathological sensation is localized 
more in the air passages represent a not rare modification 
of the intestinal somatopsychoses. In a case of the kind 
the nostrils were the site of this pathological feeling, com- 
bined with the fear of suffocation; in another the feeling 
existed that the throat is dried up and the trachea closed, 
while swallowing and eating are unaffected and no dys- 
pnoea exists. Nevertheless, a feeling of a heavy load, like 
a stone localized in the epigastrium, was felt so keenly that 6 
Outlines of Psychiatry in Clinical Lectures. 
the patient, a peasant woman of 42, called it a deathly 
feeling. It is said this feeling had gradually risen to the 
throat. The patient was troubled with an internal restless- 
ness, moaned constantly and had the most intense suicidal 
tendency. Many of these attempts had been thwarted. At 
the time of observation she had been sick a year, and it 
was learned that in the first six months self-accusations and 
fears for her family existed in still more marked anxiety. Her 
hoarseness and occasional spells of coughing were the reason 
for examining the larynx; it was found that besides the 
catarrh, which caused the vocal cords to swell, one was 
completely paralyzed. Although the suspicion of a tuber- 
cular affection of the larynx must arise in the case, the 
paralysis of the vocal cord was evidently still unexplained, 
hence the question could be raised whether it must not 
rather be regarded as a direct sequence of the hypochon- 
driacal sensation in the innervation of the larynx, in other 
words, an effect of the pathologically changed organic feel- 
ing in the organ serving motility, in the sense of my pre- 
vious remark.* The possibility that the catarrh is merely 
a sequence of the defective innervation, then finally of the 
pathological sensation, was thus afforded. However, 1 ad- 
mit that the one-sidedness of the vocal cord paralysis, con- 
traindicated this explanation and another conception of this 
rare form of disease is more appropriate. Vocal cord paralysis 
and catarrh were perhaps the common consequence of a 
latent cause not demonstrable by examination, and the 
parasthesia of the organic sensation in itself pathological 
the starting point of the circumscribed intestinal somato- 
psychosis—then to be regarded symptomatic. 
Much more probable than psychosensory akinesis in the 
sense of my prior developments is to be understood the oc- 
currence of symptoms of paralysis in cases of circumscribed 
vesical hypochondria. These cases constitute the transi- 
tion between hypochondriacal psychoses and neuroses, in 
that they encroach still less on the other mental functions 
than those previously described and may often dispense 
with institutional treatment, the more so because the nu- 
*See Alienist and Neurologist. Vol. XXIII, No. 4, page 413. C. lVernichet 
7 
merous subjective disturbances grouped with the paralysis 
of the sphincter, usually occur at certain hours of the day, 
but may be wanting at other times. Especially annoying 
is the feeling of the desire to urinate, combined in part 
with a tendency to pollutions, which may occur without 
erections. The patients are therefore in constant anxiety 
of being in distress, besides a feeling of anxiety localized 
in the epigastrium may exist. At other times than during 
the attacks the patients appear psychically normal, but in 
them they suffer from more or less pronounced ideas of au- 
topsychical anxiety and a despondency which may cause 
weariness of life and the suicidal tendency. The whole 
mode of life is usually so regulated by these patients, that 
troubles of the sort cannot occur, hence business associa- 
tion with other persons suffer. In a case of the kind treat- 
ment by warm baths for many hours, in which the patient 
felt relieved of all solicitude of sudden distress, was suc- 
cessful for a long time. 1 need not state that these cases 
are characterized by the absence of any local change and 
all symptoms in the sensory nerves and spinal cord, while 
in the preceding a previous vesical catarrh or a gonorrhoea 
seem not to have been unimportant. 
Approximately similar to the hypochondriacal neuroses 
are certain cases of defecation hypochondria, in which by 
regulation of the bowels, the chief annoying desire, like the 
anxiety with the sequela, is relieved. 
The circumscribed intestinal hypochondria is occasion- 
ally found localized, as is not otherwise to be expected, in 
the female genitals. A typical case of the sort, which I 
have presented at the Clinic, is a servant girl of 22, who, 
until her illness, had been of normal intelligence, but always 
easily excitable and inclined to outbursts of anger, whose 
brother died insane. After anger she has repeatedly had 
attacks, whose form cannot be more definitely ascertained. 
At the time of her presentation she has had for nearly two 
years, if also with a few long intervals, a burning, not di- 
rectly painful feeling, but described as wholly unbearable, 
in her genitlas and in the lower abdominal region. This 
burning was not continuous, but always soon returned. It 8 
Outlines of Psychiatry in Clinical Lectures. 
was worse toward evening and at times combined with 
pains in the sacral region, headache, vertigo and nausea. 
At the same time the patient complained of anxiety in the 
epigastrium. The disease was attended with a feeling of 
misery, profound depression, hopelessness and facial expres- 
sion, as well as the whole apathetic conduct, corresponded 
to this mental state. At the time of the menses 
the troubles were less, sacral pains and some dis- 
charge occurred before and after them. The patient’s mo- 
tor condition deserves special mention. While she usually 
remained dejected and apathetic in bed, occasionally out- 
bursts of wholly unreasonable and most absurd violence oc- 
curred, when the patient cries, strikes, bites and scratches, 
as well as totally mistakes her surroundings. The patient 
subsequently has no memory of these fits not lasting over an 
hour, they are always attended by an exaggeration of the 
abnormal sensations in the genitals, then the feeling 
occurred, like an aura, as if the body became numb and 
consciousness disappeared. We will not err if we regard 
these motor manifestations, which are of the stamp of sense- 
less violence, as a sort of reflex from the intensely exagger- 
ated organic feeling and hence as psychosensory hyperkine- 
sis. At the time of observation had ulcers of the cervix and 
vagina. Her illness had obviously followed a confinement 
and subsequent metritis. Owing to these attacks of vio- 
lence, the patient must be sent to a custodial institution. 
Although her symptoms reported so approximate the type 
of epilepsy, yet typical epileptic seizures have never been 
observed. 
Except the cases of motor discharge just considered, which 
are to be included among the dazed condition of the tran- 
sitory psychosis so-called, to be described later, a circum- 
scribed intestinal somatopsychosis, and also emanating from 
the genital organ, is expressed in the case described. The 
close relationship of attacks of violence with those of epi- 
leptic and hysterical dazed conditions is admitted, but it 
does not prevent so regarding them that the constant ab- 
normal intestinal sensation forms the starting point of acute 
transitory attacks, so that the latter appear in the light of C. Wernicke. 
9 
a reflex psychosis incited from the genital organs. In this 
transitory disturbance the identification disorder is then ex- 
tended to all three parts of consciousness, but the motor 
discharge retains the character of the psychosensory con- 
dition and thoroughly bears the stamp of somatopsychical 
perplexity. This method of consideration has the advan- 
tage of a uniform conception of the disease type. It is sup- 
ported first of all by the fact that an exaggeration of the 
local disturbances always precedes the attacks of violence, 
but further by experiences in analogous cases. I have ob- 
served, wholly isolated, an entirely similar attack of vio- 
lence in a girl of 20, who constantly had an intense feel- 
ing of misery with suicidal tendency and, once when she 
gave up her reserve and expressed herself, gave with all 
definiteness as cause of her condition, pains in the lower 
abdomen. These pains were in general of a fluctuating 
character. In the frequently recurring exacerbations of sev- 
eral days, they were described as convulsive, located in the 
region of the uterus and parametrium, combined with a ter- 
rifying feeling of anxiety ascending to the heart and ap- 
pearing with ideas of incurability and suicidal impulse. Pa- 
tient cried and moaned loudly and supervision necessary 
from her outbursts of dejection. Verbal suggestion once 
had a calming effect, more often chloroform must be re- 
sorted to. Fanciful names for the disease were wholly 
wanting. The objective condition of the genital organs led 
to the conclusion of prior masturbation (erosions of the 
vulva and vagina,with slight catarrh and bladder trouble). Fur- 
ther there was slight retroversion of the uterus and obstinate 
constipation. Sleep and nutrition were greatly impaired 
constantly. The patient, saleslady in a confectionery store, 
was the daughter of a father of unknown parentage, and 
was admitted to the Clinic after a severe hysterical ex- 
citement caused by a quarrel with her chief, in which she 
struck out blindly and cried fearfully. After six months she 
was transferred to a custodial institution, as a permanent 
improvement was not to be attained. The attack of vio- 
[ence observed by us occurred about the middle of her 
stay and was said to be caused by anger. Here, accord- 10 
Outlines of Psychiatry in Clinical Lectures. 
ing to my opinion, it would have been necessary to inter- 
pret differently the brief transitory psychosis, rendering 
prominent the rest of the picture than in the preceding 
case, moreover, the motor discharge corresponded to a 
diffuse somatopsychical perplexity. Furthermore, the patient 
was discharged from there recovered after six weeks, in 
consequence of the powerful impression which the transfer 
to a custodial institution must make on her. 
That the sense organs may be the cause of patholo- 
gical organic sensations and thus circumscribed hypochon- 
driacal or somatopsychosis, is shown by the following in- 
structive case: A woman of 71, physically vigorous, who 
until nine months ago had taken care of children and, on 
careful examination presented no signs of weakened intel- 
lect or senile mental disorder, voluntarily sought admission 
to our Clinic, because she feared she might commit suicide. 
During her stay at the Clinic of over four months she al- 
ways presented the same symptoms, until the period of im- 
provement preceding her discharge. On admission, moan- 
ing to herself, owing to anxiety in the heart. Chief com- 
plaint, a roaring in the head. The roaring is constant, 
increases in perfect stillness, so that the patient preferred 
remaining on the somewhat noisy admission ward. Subject- 
ively this roaring is extremely unpleasant, gives her no 
rest, disturbs her thoughts, engages her attention. When 
the roaring is bad, uneasiness in the heart and anxiety oc- 
cur at the same time. Feeling of intense misery, hopeless- 
ness, ideas of autopsychical anxiety, with the content of 
self-accusations, which she at the same time repudiates, 
insomnia, anxiety about the stillness of night, when the 
roaring increases, thoughts of suicide. Intelligent face, no 
defects, ability to attend good. Patient takes care of her- 
self, sleeps on hypnotics. According to the patient’s state- 
ments, this condition has slowly developed for four months. 
At first only roaring in the ears, for which she consulted 
different aurists. Then uneasiness and anxiety in the 
heart. Patient ran about here and there and could no 
longer occupy herself. Finally took too little food inten- 
tionally and suicidal ideas. The condition was always C. Wernicke. 
worse in the evening, which was confirmed at the Clinic. 
She eat well at the Clinic and during the last two months 
increased in weight from 52 to 55 kg. The results of test- 
ing the hearing and examination of the ears were interest- 
ing. Old changes in both ears, retraction of the tympanum, 
left more than right (old otitis media). On admission 
whispers understood at 3-3}4 m., stated further that the 
hearing was better or worse according to the intensity of 
the roaring. The first two months perceptible decrease in 
in the acuteness of hearing. This is manifested in ordi- 
nary conversation, in whispering the acuteness of hearing 
falls to 30 cm. on the left, 20 cm. on the right. Very poor 
bone conduction is also found, the watch is not heard on 
the head or mastoid process. An improvement in the psy- 
chical condition in the last two months was coincident with 
the favorable effect of treatment of the ears by Politzer’s 
method. On discharge the roaring was still present, a mod- 
erate feeling of illness and worry about the return of the 
old condition existed, but the anxiety, the feeling of 
misery, the self-accusations and suicidal ideas had disap- 
peared. Patient heard whispers with both ears at 5 m., also 
the bone conduction seemed improved, if worse on the 
right side than on the left. 
One of the most remarkable cases of diffuse acute 
somatopsychosis, affecting the external configuration, I will 
try to describe from notes at the time of my connection 
with the insane department at Charite. The laborer, N. 
46, was admitted December 6th, 1876, to the insane depart- 
ment as delirious. He had been admitted to one of the 
other wards on March 8th, of the same year, and after 
three days transferred to the delirious ward, but was dis- 
charged recovered on March 31st. The little data of th s 
time seemed to render the diagnosis of delirium tremens 
doubtful, while there is much that indicates he had severe 
hypochondriacal disturbances (semen flowed from him con- 
stancy, burning in the mouth, the larynx is temoved), and 
besides marked tremor and other objective signs of contin- 
ued alcoholic excess, among others the well known halluci- 
nations of sight. His restless conduct, again called delir- 12 
Outlines of Psychiatry in Clinical Lectures. 
ious, was the cause of his re-admissi n. Perfect a'lopsy- 
chical orientation and men ory of the previous sojourn, only 
moderate use of alcohol said to have preceded. Deeply 
wrinkled, sorrowful face, with anxious, nevertheless occa- 
sionally smiling expression, anxioudy accelerated respira- 
tion, no tremor of the hands, only slight tremor of the 
tongue, constant moaning and muttering. Hypochondriacal 
ideas: His brain is congea ed, he cannot speak, th ' jaws 
were so loose, the ti roat is torn, the tongue has grown 
fas and it s ems to h.m he cannot hear. These assertions 
often, v' ithout apparent affect, in a quiet, conversational 
tone. Sometimes does not respond, although spoken to 
loudly, again to whispers, then says: “He can hear, but 
there seems to be no tension in the ears,” and then puts 
his fingers in the external meati. Says his head aches. 
Protrudes the tongue after he has claimed he cannot. He 
now states anamnestica ly that it had seemed so strange to 
him for some time, but he had officiated as house servant 
to the last. Pupils quite small, equal, dilate only a little when 
sh ded. Claims to have no face, the head is almost like a 
stone. Other complaints: the rectum has been torn out, the 
head is on wrong with the face backward. Similar complaints 
chan ing in their content, which were temporarily cor- 
rected d ring the whole duration of the disease, while the 
delusion of the perverse position or his head is conspicu- 
ously fixed. Apparently no hallucinations, only at first ac- 
cessible to con olation. Gradual refusal of food, because pa- 
tient had no stomach, could get no air. Fo ced feeding 
necessary. Sleep to be obtained only by hypnotics. Ex- 
tremely peculiar motor conduct during the whole duration 
of the disease. At one time the patient used the side rails 
of neighboring beds, separated by aisles, to walk on like 
the rounds of a ladder, then standing uo in bed he let him- 
self fall out backward, again threw himself out forcibly 
while turning his body, usually for the reason his head is 
on wrong. His moaning is often so annoying that he must 
be secluded, at other times strikingly calm, even peculiar 
smiling manner in narrating his troubles, often monotonous 
reproduction of former experiences resembling verbigeration: C. Wernicke. 
13 
“N., will you stay here?” “No, Sergeant Major,” what the 
patient explains, that he had been a non-commissioned 
officer and now greatly regrets having refused the demand 
to surrender. Often ins sts in hiding himself in a corner, 
singing to himself similar experiences, as that above cited, 
never real motor symptoms. Gradual resistance and blind 
opposition to everythin:, strong clothing necessary, filthy, 
loss of strength. Many injuries from the mov ments above 
described, violently pounds himsek in the face with his 
fist, etc. Finally alternating with refu al of food o simul- 
taneously with the assertion of not being able to swallow, 
animal-like ferocity toward the food offered, so that there 
was danger of being bitten, and swallowing the food unmas- 
ticated. After a restless night, sudden calmness and death 
from exhaustion on May 4th, 1877. The autopsy showed 
besides a very marked, almost untearable thickening and 
clouding of the pia of the convexity, internal and external 
hydrocephalus, as cardinal lesion numerous encysted trich- 
inia in all the muscles, but particularly in those of the 
neck. In the supraclavicular region beneath the deep 
fascia, an area infiltrated with pus, not sharply defined and 
about the size of a pigeon’s egg, which apparently corres- 
ponds to a suppurated gland, and continued upward in the 
deep muscles of the neck to gradually disappear. Viscera 
unchanged other than signs of general marasmus. 
The manifestations of somatopsychical perplexity dis- 
played in this patient’s conduct were so peculiar that they 
are indelibly stamped on my memory. They are evidently 
rendered in part comprehensible by the autopsy, and we 
may especially assume an inner connection of the suppur- 
ating focus in the deep muscles of the neck, with the pe- 
culiar leaps often endangering life, by which the patient 
tried to correct his fancied malposition of the head. We 
shall be justified in regarding the fundamental psychosensory 
identification disorder as a pathological (psychotically in- 
duced) paraesthesia of the sense of position of the head. 
The change in the external configuration of the body 
is met with a no less instructive case 1 will now briefly 
outline. It is of a former officer of 35, of noble birth and 14 
Outlines of Psychiatry in Clinical Lectures. 
strong organic taint. Depressed at times for three years 
past, for six months he had been in the sad condition in 
which I became acquainted with him. During this time has 
slept poorly, occasionally wet the bed, impotentia coeundi. 
Except an intimated ataxia while in bed, a questionable 
speech disorder and traces of a right facial paresis, no 
demonstrable symptoms of paresis, still an old infection ad- 
mitted. Attention, memory, judgment particularly good, no 
fainting spells. Frequent deep inspirations. Feeling of 
misery, subjective incapacity for work, etc., according to his 
complaints. These refer exclusively to his body, which the 
patient says no longer feels right. It is changed, bulky, 
unwieldy, like a lump of dough, the nose has become a 
bottle nose, tongue and mouth swollen, patient cannot open 
the mouth wide enough, defecation entirely insufficient, pa- 
tient is full to the middle of his esophagus, food and drink 
have no taste, taken only from a sense of duty, a pasty, 
slimy taste in the mouth constantly, neck and throat hot 
and dry, as if burned. A peculiar feeling of anxiety is 
spoken of. On continuation of these troubles the patient 
had to be sent to the insane hospital, owing to brutal as- 
saults on his extremely sacrificing wife, and there died in 
a few months from rapidly progressive paresis. 
The example cited of hypochondriacal psychoses or 
somatopsychoses may suffice to show that the individual 
cases are of a very different stamp. We will try to em- 
brace the signs common to them all, to obtain in this way 
a differentiation from other psychoses. With respect to 
etiology we see that a demonstrable somatic affection quite 
often determines the content of the pathological identifica- 
tion disorder. Nevertheless, it may not here be a matter 
of the simple relation of cause and effect, for the same or- 
ganic affections are observed numberless times without any 
form of psj'chosis resulting. Whereas, it may be permis- 
sible to regard these cases as certain examples of psycho- 
sensory paraesthesia of the organic sensations concerned. 
The old theory of changes in position of the colon as cause 
of mental diseases now seem comprehensible in a certain 
measure and even with the restriction just given, ap- C. Wernicke. 
15 
proaches the possibility of realization in the special case. 
The form of disease is always essentially determined by 
the psychosensory identification disorder of organic feeling, 
if it is often not to be more closely ascertained whether 
paraesthesia, anaesthesia or hyperesthesia exists. 
The localization of the pathological sensations is often 
wholly indefinite and diffuse, as e. g., is especially frequent 
in the initial stage of paretic dementia, when a feeling of 
severe illness is ascribed to portentious, indescribable sen- 
sations in the whole body. Besides it may be very het- 
erogeneous and affect almost all parts of the body, including 
the sense organs, but a pure somatopsychosis can then only 
be assumed, when the comformable change in content leaves 
the allopsychical domain intact or, in other words, the cause 
of these changes in content is not sought in the world. 
Those organic sensations then, which are more conform- 
ably combined, according to their content with events in 
the world as, e. g., the sensation of piercing instruments, 
electrical shocks, contacts, etc., always exceed the bounds 
of a pure somatopsychosis, and no less the symptom of 
the delusion of somatopsychical relativity. 
Whereas, the autopsychical domain is always more or 
less involved, corresponding to the affect state induced by 
anxiety or somatopsychical perplexity. The dejected, de- 
pressed state of mind, feeling of misery, hopelessness, ideas 
of autopsychical anxiety of the most diverse content are al- 
ways to be met with. Phonemes are often conspicuously 
absent; when they occur they only serve to put the ideas 
of autopsychical anxiety and the somatic sensations into 
words. Explanatory delusions are usually, but not always 
present. From them the sensations obtain their fantastic 
explanation. Thus the concept of the mental disorder be- 
comes accessible to the laity, as e. g., when worms in the 
brain, a frog or bird in the body is complained of. Anx- 
iety, with its favorite localization in the breast, head, the 
whole body is an almost never failing attendant symptom. 
The more pronounced it is, the more real ideas of anxiety 
are manifested, and it may so dominate that it is justifi- 
able to set apart certain cases of somatopsychosis, as psy- 16 
Outlines of Psychiatry in Clinical Lectures. 
choses with hypochondriacal apprehension. Mrs. L.* re- 
cently presented, was an example. But these cases are 
well characterized by the absence of ideas of allopsychical 
anxiety and delusions of relativity. 
The patient’s motor conduct is psychologically compre- 
hensible, at one time more agitated according to the sensa- 
tions and feeling of somatic illness, again reduced to the 
verge of immobility, the linguistic expressions are analo- 
gous. The self-accusations resulting from the sensations 
claim special importance from refusal of food, suicidal im- 
pulse and actions of somatopsychical perplexity. Of such 
actions a few may be especially spoken of, for they must 
be of interest from their atrocity. They include pulling out 
the tongue, tearing off the genitals, tearing the orifaces of 
the body, gouging out the eyes, crawling into the chim- 
ney. What abnormal movements may arise from 
paresthesia of the sense of position we have seen in the 
instance of the patient, N.t 
It is an erroneous, if also authoritatively disseminated 
idea, that the boundary line between hypochondriacal mental 
disease and the hypochondriacal neuroses is thus given, that 
fantastic or explanatory delusions are wanting in the lat- 
ter. The differentiating sign is here to be sought rather 
in the influence the hypochondriacal feelings have 
on the patient’s actions. Patients, who from fear 
of committing suicide, come to the insane hos- 
pitals themselves, like Mrs. B., above described, with- 
out any fantastical explanation, will have to be considered 
insane, and likewise all those refusing food. But the ex- 
clusive concentration on the pathological feelings may con- 
dition an incapacity of the patient to engage in any occu- 
pation and to care for himself. The feeling that the lungs 
rub against each other in breathing, and acute attendant 
pains without objective lesion, forms the patient’s chief 
complaint, who combines with it not fantastical explanation, 
but is wholly occupied by the intense feeling of illness 
and so rendered incapable of any employment. I am in no 
*Sts Alienist and Neurologist, Vol. XXIV, p. 68. 
tSee Alienist and Neurologist, Vol. IXIV. Described in prior part of this lecture. C. Wernicke. 
17 
way averse to calling this example a boundary case be- 
tween hypochondriacal psychoses and neuroses. But I must 
unquestionably call another case insane, in which a gen- 
eral deterioration in motility bordering on immobility, 
without any intellectual disorder, was induced by an un- 
bearable itching in the intestines, and this not fantastically 
explained. 
The psychoses with apprehension in pure cases, as 
well as the hypochondriacal variety and the other somato- 
psychical psychoses are relatively simple disease types, 
controlled in their whole course by the same symptom com- 
plex. Their disease curve may often be constructed as 
well from the intensity as extent of the symptoms, in which 
the affect of anxiety and the motor perplexity will be de- 
cisive for the intensive curve. Where the extent of the 
symptoms remains the same through the whole course of 
the disease, which is often the case in the circumscribed 
intestinal somatopsychoses, a purely intensive curve results. 
The cases in which an extension of the pathological feel- 
ings from a circumscribed region of the body to further or- 
gans is observed, present an extensive curve, of which the 
intensive may be independent. The relation of the two 
curves is perhaps decisive for the prognosis, in that an in- 
crease in extent without corresponding intensification of af- 
fect seems t • be of unfavorable import. Besides the prog- 
nosis in all cases depends on the state of the nutrition, 
still only in the sense that the restitution of a certain 
weight forms the preliminary condition for the possibility of 
recovery and prevention of the lethal termination; in no 
way is a favorable course assured by a good state of nu- 
trition at the onset of the disease. Life is always threat- 
ened. Termination in dementia is to be anticipated in the 
paretic and hebephrenic somatopsychoses, severe organic 
taint is then to be regarded prognostically unfavorable, 
when the bounds of the hypochondriacal neuroses are over- 
stepped and unquestionable mental disease exists. Never- 
theless, th acute somatopsychoses must, on the whole, be 
included among the curable mental diseases. 
Whether a curable paranoiac stage occurs in the 'oma- 18 
Outlines of Psychiatry in Clinical Lectures. 
topsychoses, must be ascertained from further clinical ob- 
servations. Wher as the termination in chronic mental 
disorder seems to be quite frequent in cases whose acute 
character is induced more by the state of affect than by 
the duration. 
I might very briefly mention a frequent combination of 
circumscribed intestinal hypochondria with the disease type 
of affective melancholia yet to be described. The hypo- 
chondriacal feeling, of which it is a matter, is usually in- 
testinal, in women frequently arising from a feeling of 
globus in the sexual organs. These cases are entitled to 
the name of hypochondriacal melancholia, which is often 
improperly used and characterized by an absolutely favor- 
able prognosis when the treatment is early, i. e., within a 
hospital. 
In accordance with our program I now pass to a brief 
des ription of the hypochondriacal symptoms, of which I as- 
certain whether they are isolated or combined with others, 
and whether explanatory delusions and other sequential 
symptoms are present or not. When functions of organs, 
which are normally unconscious, are perceived and accom- 
panied by pathologi al sensations, we will have to regard 
them examples of psychosensory hyperesthesia. Here be- 
longs the digestive process of the stomach or intestines, af- 
ter partaking food. This symptom increased from a slight 
fe ling of discomfort to wholly fantastic derangements, is 
very often met with in insane and combined usually with 
the explanatory delusion, that poison is mixed with the 
food. An actual gastric catarrh is quite often the starting 
point of the pathological identification and leads to the 
complaint of feeling of weight, as though there was a 
stone at the pit of the stomach. The localized anxiety in 
affective melancholia may often be of this origin. The sense 
of burning, boiling, drawing, glowing in the viscera of the 
th rax and abdomen occurs frequ ntly in insane. The heart 
is th starting point of numerous disturbances; it cither 
beats too fast or too slow, seems to the patient to stop, 
the blood to stagnate in the veins. In a patient of Kal- 
baum’s, a painful sensation in the heart was referred to C. Wernicke. 
19 
the sight of the fire on the hearth: the heart was burned 
out. Muscle pains are often the basis of a very intense 
feeling of illness, as several examples of rapid restoration 
by relief of the muscle pains proves. It also depends on 
hyperesthesia when moderate muscular exertion, a in 
standing, walking and sitting, induces a feeling of great 
fatigue and thus the idea of loss of strength and hence the 
approach of death. The idea of having consumption and 
therefore of being about to die, may usually be traced to 
muscle pains in the thorax. It might be due more to in- 
testinal feelings, when the lungs are said to be suppurating 
or gangrenous, in part a misconception of the expectorated 
pharyngeal and nasal mucous exists, often a corresponding 
hallucination of smell also. 
The ! rain is an especially fertile source of hypochon- 
driacal sensations. Th idea is uncommonly prevalent 
that it move, in the skull, an overflowing or fluid, oozing, 
trickling feeling is described. Also the sensation that the 
brain is shriveled up, dried, that it glows, is corroded, is 
often stated. A crawling, creeping feeling is lo ated on the 
brain surface and ascribed to little animals. The sensa- 
tion that the brain substance is effected by external 
agencies leads to the idea of machines and persecutors. A 
patient describes different nerves which arise in the brain; 
he compares them to wax candles of different lengths and 
exactly designates the places where he feels them. A 
sighing, roaring, thundering is often expressly located in 
the brain, not in the ears. 
The feeling of being hollow must depend on very curi- 
ous sensations, in that the pati -nts often expressly state 
that the food taken falls into a cavity! A patient expressed 
the idea that the diaphragm is broken through and the air 
at every respiration enters the abdominal cavity. These 
serious sensations are especially frequent in paretics. 
It is specifically paretic when patients say that there 
are laborers in their brains, who do a certain work and 
send out loaded wagons, when patients claim to have a reg- 
iment of soldiers, a factory or a church in their body or a 
number of brandy casks under the skin. Whereas, the 20 
Outlines of Psychiatry in Clinical Lectures. 
statements of insane women of being pregnant, or of hav- 
ing just been delivered or of having a severe pelvic 
trouble, depend on certain normal sensations. 
The changes in the external configuration are quite 
often felt. The cranium is very often said to be soft and 
yielding to pressure; again it is stated that the thorax has 
fallen in or is deformed, the shoulders not in the proper 
place, either too high or too low, the limbs are abnormally 
large or long. A young lady believed she was abnormally 
ugly and to have an ape’s cranium. She roughly outlined 
its form with sagittal median eminences and claimed to 
recognize an ape’s face in the mirror. A patient acutely 
ill claimed to feel the right leg on the left and the left on 
the right, another to have more than four arms of very dif- 
ferent lengths. Another patient became acutely ill with at- 
tacks of the most intense somatopsychical perplexity and 
disorientation. Although held by several strong men, he 
could scarcely be prevented from gouging out his eyes with 
his fists. The hematomas remaining after the attacks, by 
which the uninjured bulbi were covered, showed the loca- 
tion of his worst sensations, of which the patient likewise 
had no memory. Whereas, in a lucid interval so called, 
he stated the worst thing in his seizure had been the in- 
describably terrible feeling of no longer knowing the rela- 
tion of the trunk, head and limbs to each, which was above 
and below, right or left. A few seizures of the kind re- 
sulted in profound dementia. The patient of a family with 
strong hereditary taint, died in about a year from progres- 
sive paralysis. The idea of being abnormally small or ab- 
normally large, is particularly common to paretics. The de- 
lusion of some physical transformation, e. g., a woman into 
a man, or into an animal, seems to depend in part on the 
sensation of changed configuration of the body. 
It is to be regarded as psychosensory paraesthesia of 
the senses, when the patients say they are dazzled and 
claim they cannot see. We have become acquainted with 
the insensibility to pain, e. g., in the patient above men- 
tioned, who pounded his face to demonstrate that he felt 
no pain. Pains of hypochondriacal origin are frequent in C. Wernicke 
21 
the insane. They complain that they are prodded out of 
bed with pointed knives, that they are electrified, tortured, 
tormented, their limbs are broken, etc. The pains are 
often more definitely described as burning, glowing, boring, 
tearing, throbbing. Painful muscular contractions are ex- 
plained by electrical shocks. A patient of Kahlbaum’s com- 
plained: “Why do you dish me out so?” as she saw the 
attendants apportioning the soup. These are all undoubted 
examples of psychosensory hyperaesthesia of the general 
feeling. I have heard the statement from patients, who are 
in the habit of holding the head up from the pillow, bent 
forward when in the recumbent posture, that they had the 
feeling that their head fell backward. The maintenance of 
abnormal positions, which we will later meet with fre- 
quently in a certain class of patients, usually has its 
origin in an identification disorder of the sense of position. 
It may be the same with the so-called hypochondriacal 
paralysis, of which I remember an example of right hemi- 
plegia with mutism at Charite. The autopsy of this case 
was negative. 
The sensation of cohabitation, of which female insane 
ve y often complain, must be regarded as a complex 
sort of psychosensory identification disorder of general sen- 
sation. It is rarely possible to obtain a more definite ex- 
planation and it is then stated either the feeling of a hard 
body moving back and forth in the vagina, or it is a mat- 
ter of a combination of hallucinations of the dream-like va- 
riety, in which tactile and general sensations unite in the 
whole act of cohabitation. A similar event is described by 
male patients as handling or grasping the sexual organs, 
and projected outward. The complaint of sexual indignity 
by male patients is very often heard. 
Indefinite parassthesias of general sensation, probably 
combined with abnormal muscle and organic sensations, are 
those of being drawn,\i. e., the whole body is drawn in a 
certain direction, a sensation which occurred in one patient 
as a reflex sensation, when he looked at the gas jet burn- 
ing under the ceiling. Further, the feeling of swaying, be- 
ing raised or falling, perhaps in part to abnormal identifi- 22 
Outlines of Psychiatry in Clinical Lectures. 
cation of the feeling of dizziness, further to the delusion of 
being able to fly. The latter idea was held for months by 
a case I observed at Charite, and led, among other things, 
to the awkward situation, that the patient climbed a tree 
in the garden and swung on much too weak branches, so 
that a dangerous fall seemed unavoidable. The employ- 
ment of the fire hose only resulted in the patient changing 
his position and therefore it had to be abandoned as use- 
less. But it all came out right, for the patient descended 
after being left entirely alone and the garden cleared.