MANUAL 
PSYCHIATRY 
for the 
MEDICAL STUDENT and GENERAL PRACTITIONER 
By / 
PAUL E. BOWERS, M.S., M.D. 
♦ / ♦ 
Examiner in Lunacy, State of California ; Neuropsychiatrist, 
Los Angeles General Hospital; Lecturer in Neuropsychiatry, 
Post-Graduate Medical School of the University of California, 
Los Angeles; Regional Consultant, United States Public 
Health Service 
PHILADELPHIA and LONDON 
W. B. SAUNDERS COMPANY Copyright, 1924, by W. B. Saunders Company 
MADE IN U. S. A. 
PRESS OF 
W. B. SAUNDERS COMPANY 
PHILADELPHIA PREFACE 
The worker in the field of medical science, whether he be 
student or practitioner, is frequently confronted with problems 
relating to mental disorders. In order to solve these problems 
effectively he should possess a working knowledge of psychiatry. 
He should be familiar with the symptomatology of mental 
disease and the diagnosis and treatment of the various types of 
mental derangement, and be able to bring sound, practical and 
detailed judgment to bear upon the many and divers situations 
that present themselves to him. 
It is the purpose of this volume to give a comprehensive and 
systematic outline of the field of psychiatry, and to afford the 
student and the general practitioner a reference handbook to 
which they can turn for definite, detailed information upon the 
different aspects of mental medicine. 
The material comprising the various chapters has been 
digested, so far as is consistent with clarity and comprehensive- 
ness or subject matter, in order that the information may be 
readily available. However, nothing which would add to the 
value of the presentation has been sacrificed for the sake of 
brevity. 
All controversial discussions have been excluded, in order that 
the information contained should be of permanent and authentic 
value. This greatly enhances the utility of the volume for the 
medical student. So far as possible, conjecture and supposition 
have given way to reliable conclusions and data. 
I acknowledge my indebtedness to many works already in the 
13 14 
PREFACE 
field, from which I have felt free to collect information which has 
contributed to the worth of this volume as a compensation. 
Paul E. Bowers. 
Los Angeles, California, 
October, 1924. CONTENTS 
CHAPTER I 
PAGE 
Psychological Introduction 17 
CHAPTER II 
Definition and Classification of Mental Disorders 27 
CHAPTER III 
Causes of Mental Disease 37 
CHAPTER IV 
Symptoms of Mental Disorders 44 
CHAPTER V 
Traumatic Psychoses 67 
CHAPTER VI 
Senile Psychoses 72 
CHAPTER VII 
Psychoses With Cerebral Arteriosclerosis 79 
CHAPTER VIII 
General Paresis 83 
CHAPTER IX 
Psychoses With Cerebral Syphilis 95 
CHAPTER X 
Psychoses With Brain and Nervous Diseases 102 
CHAPTER XI 
Psychoses Due to Alcohol, Drugs and Other Exogenous Toxins 106 
CHAPTER XII 
Psychoses With Somatic Diseases 130 
15 16 
CONTENTS 
CHAPTER XIII 
PAGE 
Manic-Depressive Psychoses 146 
CHAPTER XIV 
Involutional Melancholia 156 
CHAPTER XV 
Dementia Pr.ecox or Schizophrenia 162 
CHAPTER XVI 
Paranoia and Paranoid States 178 
CHAPTER XVII 
Epileptic Psychoses 185 
CHAPTER XVIII 
The Psychoneuroses and Neuroses 193 
CHAPTER XIX 
Psychoses With Constitutional Inferiority 215 
CHAPTER XX 
Psychoses With Mental Deficiency 238 
CHAPTER XXI 
Diagnostic Groupings of the Symptoms of the Psychoses 248 
CHAPTER XXII 
Methods of Examination 260 
CHAPTER XXIII 
Binet-Simon Scale of Intelligence Tests 285 
CHAPTER XXIV 
Treatment 298 
CHAPTER XXV 
Relationship of Insanity to Crime 313 
Bibliography 351 
Index 353 MANUAL OF PSYCHIATRY 
CHAPTER I 
PSYCHOLOGICAL INTRODUCTION 
The student and the general practitioner of medicine are 
familiar with the anatomy and physiology of the central nervous 
system, and a description of these essentials is unnecessary and 
out of place in a book of this size. Only the cardinal points and 
basic principles of the underlying psychology will be touched 
upon in this chapter, and these are taken up solely because it 
is necessary to show in what manner and to what degree the 
ordinary psychological functions may be disordered. 
The adrenals secrete adrenalin, the liver secretes bile, and, as 
one noted authority has said, it is the function of the brain to 
secrete thought. This is a very apt and expressive analogy, but 
psychologically it is not quite correct. The brain is the organ 
of the mind and without the brain there is no expression of 
mental life. Impairment of the brain in the frontal lobes of the 
cerebrum produces certain definite losses and impairments of the 
intellectual capacities, which would indicate that the brain is the 
seat of consciousness. 
The term "mind" is not susceptible to a definition which 
entirely and properly tells what it is and defines its powers and 
uses. To say the mind is the intellect is but to beg the question 
and use a synonym. Without entering into any abstruse theories 
concerning its character, which psychology has yet failed to 
determine, it may be somewhat defined, for the purposes of this 
book, by giving a definition which implies its use. The mind is 
17 18 
MANUAL OF PSYCHIATRY 
the sum total of intelligence and awareness of that intelligence, 
at any particular given moment; or, the mind is that expression 
of mental life which manifests itself through the organization of 
the central nervous system in the process of thinking, feeling 
and acting. Consciousness is the state of awareness, in an 
individual, of his personality; a recognition by the individual 
that he lives as distinct from other persons. The afferent nerves 
of the body carry the impulses of the outside world to the brain, 
and the carrying of these impulses and their interpretation is 
called sensation. To the interpretation of sensation psychologists 
have applied the term perception. The process of perception 
may be illustrated in various ways. In the room where an 
individual reading this book may be sitting, there may be a 
flower in a vase. The flower is red; it gives off an agreeable 
perfume. The leaves of the flower have a peculiar serrated edge, 
and along the stem are thorns. In the process of thinking, in 
which perception is the first step, the individual receives the 
impression of redness. He notices the agreeable perfume. To 
the first impression has been added a second. Other perceptions 
are added as the individual interprets and sees the shape and 
character of the leaf or the flower. On attempting to pick up 
the flower his finger is pricked by the thorns on the stem. Defi- 
nite groups of perceptions have been united which form new 
conceptions and give the individual the idea of a rose. In 
grouping these ideas the memory is called into play. Memory 
is the recurrence to consciousness of past experiences, or we may 
say in another form that memory is the power of the mind to 
reproduce past states and experiences. 
It was once taught by the older psychologists that the mind 
was composed of certain definite functions which were catalogued 
and pigeonholed, as it were; that the mind was made up of 
certain definite compartments and each compartment or faculty 
of the mind had a definite function to perform, and that these PSYCHOLOGICAL INTRODUCTION 
19 
different faculties could function independently of other faculties 
so long as the integrity of the brain was not disturbed. This 
idea of the mind is erroneous and is not accepted by modern 
psychologists. The mind may be thought of, as illustrated in the 
diagram, as a circle which has a continuity and intimate asso- 
ciation even though there are three very definite duties performed 
by the mind which are indicated by the lines subdividing this 
circle. The terms of the older psychologists are of value for the 
purpose of description. The mind has three definite functions: 
1. The Function of Intellection, or Thinking. 
2. The Function of Emotion, or Feeling. 
3. The Function of Volition, or Willing. 
These different functions are expressions of continuous inter- 
connections between the whole of consciousness and are not 
separate processes, as was once held. These functions may be 
graphically described as follows: 
The grouping of a number of perceptions results in the forma- 
tion of a new conception, and the grouping of one conception 
with other conceptions forms an idea. One idea is weighed, 
compared and associated with other ideas, and to this process 
the term reasoning has been applied. Reasoning (or comparing 
ideas) establishes a new idea, to which is applied the term judg- 
ment. The comparison of judgments results in the formation 
of new judgments. 
Every thought or idea is attended by feelings that are agree- 
able or disagreeable. No thoughts are entirely neutral, so far 
as emotion is concerned. The emotional association of thought 
may be very slight or it may be extreme. The idea of the rose 
as given to illustrate the process of thinking cannot exist without 
some feeling that is pleasurable or painful. The color, the form 
and fragrance of the rose may be pleasurable, yet it may awake 
a train of ideas which are essentially painful and disagreeable. 20 
MANUAL OF PSYCHIATRY 
An individual may be of artistic temperament. The beauty 
of the rose makes a particular appeal to a person of this type, 
and the individual may be stimulated with a desire to produce 
a likeness of this rose with paint and brush. The desire to do 
this skillfully entails a line of thought and feeling. The indi- 
vidual may be ambitious to succeed as a painter, and this 
ambition may be built upon his desire to care for those who 
are dependent upon him. This is the vicarious expression of 
the love and affection he has for his family and children. The 
other forms of emotion, such as hate, anger, jealousy, etc., need 
no description. We see now by this illustration that the process 
of thinking has been in action, the emotions have been aroused, 
and, in this particular instance, to every idea there has been 
attached more or less of a feeling of pleasure. 
The individual may wish to become a successful painter in 
order that he may acquire both honor and money, but he cannot 
do so unless he exercises the power of volition or will. He pro- 
cures the necessary paint, palette and brushes, and canvas upon 
which to paint the flower. The action of securing these things is 
a deliberate, voluntary action. As he places the flower in a vase 
before him he accidentally pricks his finger. His hand is 
instinctively withdrawn. The withdrawing of the hand was an 
automatic reflex action, but nevertheless belongs to the domain 
of volition. As he moves about the room to accomplish his 
purpose he starts walking. Walking is started by a deliberate 
action of will power, but once initiated it continues without 
mental effort. This is an automatic expression of the power of 
volition. 
The painter may be ambitious to paint the flower at once, but 
the intellectual processes of his consciousness warn him of the 
fact that he cannot accomplish his aim without certain definite 
preparation. Before he wields the brush he must study the 
flower carefully, know the shape of its petals, ascertain the rela- 21 
PSYCHOLOGICAL INTRODUCTION 
tion of one petal to the other. This act of the will power which 
restrains him from a hasty painting of the rose is the inhibitory 
power of the will-the power to restrain action. From the 
psychological viewpoint this is possibly the highest attainment 
of the volitional function of mind. 
By this illustration it has been shown that the perceiving of 
the flower, the feelings that it has engendered, and the activities 
of the three various functions of the mind considering the rose, 
have all been correlated and continuous. 
It is essential for the reader to get this idea, in order that he 
may properly understand in what manner insanity in its various 
forms affects these three functions of the mind. As is stated in 
the second chapter, in insanity there is a prolonged departure 
from the individual's usual manner of thinking, feeling and act- 
ing. We may further continue with the rose to illustrate these 
disturbances. 
An individual may suffer from some form of insanity due to 
the introduction of a poisonous substance, such as alcohol, into 
the body. Delirium tremens may be produced, and the indi- 
vidual suffering from this psychosis may interpret the red rose 
to be a splotch of blood. The stem may appear to be a snake. 
As the result of this wrong interpretation of sensory impressions 
concerning the rose, the individual's emotions are aroused. He 
is greatly frightened. His face is blanched by fear. His heart 
may beat at a rapid rate. The hair on his head may rise. His 
teeth may chatter, and other signs of a great fear may be 
exhibited. Out of the disorder of his perceptions and the arising 
of the painful ideas concerning his misinterpretation of the rose 
the individual's inherent tendencies of self-preservation assert 
themselves and he attempts to rid himself of the snake by 
striking the flower with a cane or any other object that may be 
used as a weapon. Here there is a disorder in his conduct. The 
harmless flower and the vase which contains it are destroyed by 22 
MANUAL OF PSYCHIATRY 
reason of the fact that the individual has in the first place 
thought wrongly, and in the second instance has felt wrongly 
about his environment, and, thirdly, his conduct has been 
unusual and a departure from the normal. 
In the preceding paragraphs the subject of psychology has 
been dealt with largely in a descriptive manner. We will now 
turn our attention for a short while to that portion of modern 
psychology which deals with the question of behavior, or which 
has been termed behavioristic psychology. This department of 
the study of mental life deals with human conduct and seeks 
to explain the reasons for types of human behavior. 
In order to know how the mind acts and what forces are 
behind human behavior, it will be necessary to point out in a 
brief way the origin and stages of development of the mentality. 
Just as the body develops, there is in a normal individual a 
corresponding development of mind. During the infantile period 
of the individual's life, his parents or those who take the place 
of his parents, whether it be individuals or the state, supply him 
with the necessities of life. The child does not have the capacity 
to acquire these necessities himself, and makes his wants known 
by crying or talking, depending upon his age level. As the 
person grows older he finds it necessary to develop certain defi- 
nite powers to acquire food and clothing, and in order to do so 
he enters into competition with his fellows and into conflict 
with the conditions of his environment which hinder him from 
securing what he desires. 
With the development of the powers of the mind, new and 
enlarged conceptions of life take place. The individual becomes 
discontented with what he has. Spurred on to accomplishment 
by the dynamic force of discontent, he strives to fulfill his ever- 
increasing demands. He finds, however, that he must conduct 
his struggle along lines that have been appointed and fixed by 
social customs, and if he deviates from the established methods PSYCHOLOGICAL INTRODUCTION 
23 
of satisfying his desires he is likely to be regarded as anti-social 
and criminal. The wide gulf between an individual's ambitions 
and his power to gratify them is the source of the conflict which 
is the basis of mental development. 
Among both the sane and the insane two methods are pursued 
to secure the satisfaction of desires. One method is to do those 
things which will gain for the individual that which he wants. 
The other method is to use the fairyland of childhood and "make 
believe." The first mode of effort results in voluntary acts. By 
the second method the individual escapes the realities of life and 
avoids the conflicts and pains attendant upon them by day- 
dreaming and wishing. 
As the normal individual grows older mentally he exercises 
the power of judgment and sacrifices the gratification of tem- 
porary desires to a well-outlined plan of accomplishment which 
is worth far more to him in his struggle for attainment than the 
mere satisfaction of an infantile whim. The desire for the imme- 
diate gratification of wishes is pushed into the background of 
consciousness by what the psychologists call repression. With 
the process of mental development the subconscious or uncon- 
scious mind is surcharged with repressed ideas and desires. To 
note this fact is essential in the practice of psychiatry, for out 
of this limbo of the unconscious spring the disorders, in many 
instances, of human conduct-"mental diseases." 
In the various mental disorders we find that the mentally 
unbalanced individual does not pursue the usual lines of conflict 
in his endeavor to satisfy his wants. The perceptions are dulled. 
Often he fails to distinguish the rights of others, as is well 
illustrated by the conduct in paresis. In this disease the indi- 
vidual fails to understand the property rights of other persons 
and he appropriates to himself whatever may be in his reach. 
Stealing is often a symptom of paresis. The hysterical individual 
suffering from some mental trauma of a sexual nature, by the 24 
MANUAL OF PSYCHIATRY 
aid of phantasy creates an unreal lover. An individual's mind, 
growing limited by reason of a dementing process, withdraws 
into itself. Those things which he would like to have, and which 
he cannot attain by voluntary effort, are supplied to him by 
the fabrications of delusional states of mind. It is the wish- 
fulfilling propensity which accounts for the nature of many of 
the delusions of the insane, and often explains the mechanism 
of their disordered fancies-hallucinations and delusions. 
As ataxia occurs in tabes dorsalis, so there is found among 
persons suffering from mental disorders a state of mental ataxia 
in which there is a marked incoordination existing between the 
various functions of thinking, feeling and acting, and this con- 
dition of disequilibration is responsible for many of the well- 
defined symptoms of insanity. The hysterical individual may 
suffer from astasia abasia because there is not the proper inter- 
action between the processes of thinking and the functions of 
the volitional qualities of mind. Likewise the hysterical indi- 
vidual suffers from paroxysmal convulsions because of disorders 
of the will and the emotions. The accumulated disorders and 
emotional impulses are exploded in uncoordinated, unproductive 
muscular activities. The powers of volition are in abeyance, 
and because of the hysteric's self-centered attitude of mind it 
is impossible for him to perceive his environment in the proper 
manner and to make intelligent judgments. 
In dementia praecox there is marked ataxia between the emo- 
tions and the intellectual and volitional powers of the mind. The 
dementia praecox patient may be depressed and have apparent 
reason to be so, yet his conduct at the time of apparent depres- 
sion is in absolute opposition to the content of his consciousness. 
He cries when he should laugh, and vice versa. 
The mind may be compared to steam in the boiler of an engine 
and the brain and body to the mechanism of the engine. If the 
steam is applied to the steam chest so that it may act upon the PSYCHOLOGICAL INTRODUCTION 
25 
piston in the proper manner, the engine is propelled smoothly 
along the tracks. If, however, there is an escape of steam 
through the safety valve or through leaky pipes leading to the 
steam chest, or if there is interference with the motion of the 
piston, the engine does not move as it should. So when that 
expression of life called mind manifests itself through the 
medium of a disordered brain, there is produced a perverse, 
defective or abnormal action of the mentality and an improper 
discharge of mental energy, resulting in disorders of conduct or 
mental disease. 
Diagrammatic Explanation of the Mind or Psyche, 
Showing the Manner of Its Activities 
Mentality is represented by a circle within which is a smaller 
circle representing the consciousness, used to indicate that the 
individual is aware of his own existence and conscious of the fact 
that he thinks, feels and acts. 
FRIGHT 
.HAM 
ANGER 
FEAR 
LCCffi 
REFLEX ACTS 
[automatic ACTS 
VOLUNTARY ACTS 
jIEBSmwt 
BE4£OTING_ 
IPEATION 
MEMORY 
CONCEPTION 
PERCEPTION 
HMSATIQH - 
NORMAL VOLUNTARY ACTS 
/ 
NORMAL INHIBITORY ACTS 
Normal 
■ Conduct or 
Sanity 
Abnormal 
'Conduct or 
Insanity 
. .WSSSSAkiQSS - . -. 
JEEEPmR.MJUBWPBXJkCIS..*. 
Fig. 1 
From the outside world there is carried into consciousness a 
stimulus through the afferent nerves, and the recognition of this 
stimulus produces a sensation.. Sensation leads to a perception. 
The perceptions are multiplied to form conceptions. New con- 26 
MANUAL OF PSYCHIATRY 
ceptions are called into being by the process of memory, and by 
the comparison of present conceptions with those of the past, 
ideas are formed. These ideas are grouped, comparisons are 
made and new ideas are formed. This process of grouping ideas 
and comparing them is known as the process of reasoning. As 
the result of the process of reasoning, judgments are formed. 
The process of thinking, which began with sensation, is con- 
tinued, and each thought is attended by some feeling which is 
agreeable or disagreeable. Various emotions are mentioned in 
this diagram for the purpose of illustration. As the result of 
thinking and the emotional content of the mind, definite volun- 
tary and inhibitory acts take place. An individual's action in 
relation to his environment is termed conduct. 
This diagram illustrates that the normal processes of thinking, 
feeling and acting are continuous and connected, from the first 
step in intellection, that of sensation, to the last step, that of 
acts resulting in conduct. The dotted line is used to indicate 
that there is some definite disorder or perversion of the intel- 
lectual, emotional or volitional function, singly or together, 
which results in disordered conduct or insanity. CHAPTER II 
DEFINITION AND CLASSIFICATION OF MENTAL 
DISORDERS 
The practitioner is called upon in his daily work to solve 
problems and to bear responsibilities of every variety and degree, 
which demand for their solution a broad medical knowledge 
and a keen sense of diagnosis. Major surgery often becomes 
his duty in times of stress and necessity. The problems of public 
health are in his keeping. In his role of family physician and 
adviser, enigmas of the most delicate nature are submitted to 
him, and not the least of the problems which confront him are 
those pertaining to the subject of mental disease. 
Often the general practitioner is called upon to pass an opinion 
as to whether or not an individual possesses testamentary ca- 
pacity. Again, he is a member of a lunacy commission, there 
to certify whether or not a citizen is insane, and whether or not 
he should be deprived of his liberty and the right to control 
property. Frequently he is asked by the court to testify in 
the capacity of expert witness as to the sanity or insanity of 
an individual who has committed a crime or misdemeanor. In 
this role the physician's skill and patience are often tried to the 
last degree because of his limited working knowledge of mental 
disease and the difficult conditions under which he is compelled 
to testify. 
The term "insanity," as generally employed, is a fruitful 
source of confusion and misapprehension, because one fails to 
discern that this word as commonly used is a legal term. When 
the general practitioner is called into court as a medical witness 
he should make plain in giving his testimony that there is a 
27 28 
MANUAL OF PSYCHIATRY 
difference between medical and legal insanity. The medical defi- 
nition is one concerned with any deviation or departure of the 
individual from his usual or normal manner of thinking, feeling 
and acting. The law is concerned with what the individual does, 
what he may do, and whether or not he is responsible (and the 
method of determining this responsibility), and in what way 
society shall be protected from the mentally irresponsible. The 
law is not concerned with any pathology in a person's mental 
constitution or behavior unless that person's relationship to 
society is so altered that there is conflict with the legal rights 
of others. The technicalities of psychology and psychiatry do 
not concern the law except as they may be interpreted by the 
physician at the order of the Court, to aid in the administration 
of equity and justice. 
The aim of medicine is the restoration of the individual to 
his normal mental status. The law seeks the protection of 
society and is not concerned with the individual except in his 
relation to the social body. It is therefore apparent that a 
person may be insane in the medical conception of that term, 
and as such require medical treatment, but unless his actions 
are of such a nature as to require legal restraint, he is not legally 
insane. 
Aside from the legal aspects of insanity, the imperative neces- 
sity for the early recognition of mental disorder is obvious. If 
one expects to secure favorable results in the treatment of the 
insane, the proper medical measures and isolation must be insti- 
tuted before organic changes develop in the brain substance, 
or before the underlying physical diseases have progressed so 
far as to make restoration impossible. By the early recognition 
of mental disorders it is possible to protect patients and their 
families against serious disgrace and financial loss which might 
otherwise be incurred. In order to perform the important duties 
which devolve upon the general practitioner, it is essential that DEFINITION AND CLASSIFICATION OF MENTAL DISORDERS 
29 
he make himself familiar with the varied manifestations of a 
disordered mentality. 
Many times the practitioner is called upon to define the term 
insanity. Various attempts have been made to do so, but all 
definitions so far given are more or less imperfect. A perfect 
definition of insanity is impossible. The following one is to 
the author the most practical and it meets at least a majority 
of the medical and legal requirements and for this reason it may 
be of service here: 
"Insanity" is a legal and generic term which is used to define 
the group of diseases or psychotic reactions in which there is a 
disorder of the mind due to disease of the brain or other organs 
of the body, "manifesting itself by a more or less prolonged 
departure from the individual's usual manner of thinking, feeling 
and acting," and resulting in a lessened capacity for adaptation 
to his environment, to the degree that the individual may be 
certified before a legal authority, that he may be deprived of 
his civil rights. 
It will be noticed that the definition emphasizes the departure 
from the usual. This may show itself in a change of charac- 
teristics, emotions, morals and conduct, or it may be evidenced 
by an exaggeration of the natural tendencies. It is necessary 
that this departure be more or less prolonged, or else the defini- 
tion would include many temporary deviations of thinking, 
feeling and acting, such as those resulting from the temporary 
effects of alcohol, the delirium of fever, the conditions of con- 
fusion and the unconsciousness following traumatism. These 
transient departures do not constitute legal insanity. This defi- 
nition speaks of the individual's normal mental status. We 
cannot compare the behavior of one individual with that of 
another, for no two individuals think, act or feel alike under 
the same environment. It is therefore necessary, in our attempt 
to diagnose an individual's mental status, that we compare his 30 
MANUAL OF PSYCHIATRY 
present actions with his past behavior, and in relation to the 
usual standards of his race and nationality. 
Mental disorders have been classified upon the following bases: 
Etiological 
Psychological 
Pathological 
Clinical. 
ETIOLOGICAL CLASSIFICATION 
None of these classifications can be complete or strictly accu- 
rate for all mental disorders. The etiological factor may appar- 
ently be the same and yet in various psychoses very widely 
different types of disease may be produced, as is the case with 
the etiological factor alcohol. This drug does produce many 
varieties of mental disorder. The varieties are dependent upon 
the reaction of the individual to the drug. Alcohol may be the 
exciting factor for the production of delirium tremens, alcoholic 
hallucinosis, Korsakow's psychosis and other forms. 
Syphilis produces a variety of mental symptoms. Often two 
etiological factors will act together in the production of a mental 
disorder, and in some forms of alienation the etiological factor 
can not with absolute certainly be determined. 
PSYCHOLOGICAL CLASSIFICATION 
Attempts have been made, especially in recent years, to classify 
mental diseases upon a psychological basis, and while a classi- 
fication upon such foundation answers in a number of instances 
it fails in others. A psychological explanation of syphilitic 
psychoses is not satisfactory, because the all-important factor 
in this group of mental disorders is syphilis, and the recognition 
of syphilis as the causative factor determines in a large measure 
the treatment the patient is to receive. Psychology may explain DEFINITION AND CLASSIFICATION OF MENTAL DISORDERS 
31 
the mechanism of the patient's delusions or hallucinations, but 
it has no therapeutic value in this instance. On the other hand 
the psychological analysis of hysteria is of great material value 
in assisting the hysterical patient in making an efficient adjust- 
ment to the society in which he lives. 
PATHOLOGICAL CLASSIFICATION 
In general medicine the safest classification of mental diseases 
is made upon the pathological basis. Only a few of the mental 
diseases can with absolute certainty be classified from such a 
viewpoint, because we have thus far failed to discover sufficient 
pathology in the brain substance or any other parts of the body 
to account for the symptoms the patient may exhibit. Often 
the symptoms are far in excess of the slight pathological condi- 
tions that are found, and the reverse is true. The pathology 
of dementia prsecox is still a matter of question. Certain patho- 
logical conditions have been found to exist with the dementia 
prsecox group of diseases, yet it is difficult to distinguish between 
the anatomy that is associated with this disease and that which 
stands in etiological relationship to it. 
CLINICAL CLASSIFICATION 
The oldest and most popular method of classifying diseases 
has been upon the basis of clinical findings. Certain groups of 
symptoms have been found to occur with great regularity when 
certain etiological factors were present, and this grouping has 
been more or less constant. As a result of this uniform grouping 
of symptoms certain forms of mental disorder were thought to 
be definite clinical entities, and to each group of symptoms 
there was given a definite label. The naming of mental dis- 
orders has been essential in the development of psychiatry and 
has served to arrange the phenomena of mental medicine in a 
more or less concise, definite and orderly manner so that a work- 32 
MANUAL OF PSYCHIATRY 
ing basis was possible. However, it is at once apparent that 
this method is likewise faulty. A state of mania or depression 
may occur as a part of the clinical picture of all the psychoses, 
yet it would be fundamentally wrong to call every state of 
alienation, melancholia, because the patient exhibited depressive 
symptoms. Obviously it is likewise wrong to call all diseases 
paranoia in which delusions of persecution are found. Classify- 
ing mental diseases upon symptoms alone has often resulted in 
the overvaluation of certain symptoms and the consequent 
obscuring of the etiological factor of the disease, to the injury 
of the patient. In former times, when a patient's mental disorder 
was labeled, the clinician was often inclined to think that his 
duty had been done. This was only too true of dementia prsecox. 
Too often the patient was placed in a hospital for the insane, 
and looked upon as hopelessly ill, because his disease had been 
classified as dementia prsecox. This nihilistic attitude is rapidly 
passing away under the modern dynamic trend of psychiatry. 
The modern tendency in psychiatry is to use names as vehicles 
of thought, chiefly so that there may be an agreement of defini- 
tion for practical working, but the greatest effort is put forth 
to study the individual in relation to his life history and his 
manner of adjustment to his environment. We seek to get a view 
of the patient in longitudinal section rather than in cross section. 
We study his type of reaction to social conditions. The indi- 
vidual is analyzed not upon a single classification, as was often 
attempted in former days, but with a view to discover, if pos- 
sible, the etiology which lies at the base of his trouble. [This 
can only be done by a careful investigation of the etiological 
and pathological conditions found, the psychological analysis 
of the mechanism of his symptoms and the proper grouping and 
arranging of the symptoms which the patient exhibits. In other 
words, very briefly, an attempt is made to understand the patient 
and not merely to classify his disease. The classification of DEFINITION AND CLASSIFICATION OF MENTAL DISORDERS 
33 
mental diseases which recognizes and embraces all four aspects 
of the problem just touched upon is the one that is most satis- 
factory for the teaching and the practice of psychiatry. 
In this volume the classification of mental diseases as outlined 
by the American Psychiatric Association will be followed, except 
for slight modification. This classification has been approved 
by the National Committee for Mental Hygiene, and is being 
used by the most progressive institutions in America. The 
chapters outlined will follow the arrangement here shown: 
Psychoses, Traumatic 
Traumatic delirium 
Traumatic constitution 
Post-traumatic mental enfeeblement. 
Psychoses, Senile 
Simple deterioration 
Presbyophrenic type 
Delirious and confused states 
Depressed and agitated states in addition to deterioration 
Paranoid states 
Pre-senile types. 
Psychoses with Cerebral Arteriosclerosis 
General Paralysis 
Tabetic type 
Cerebral type. 
Psychoses with Cerebral Syphilis 
Psychoses with Huntington's Chorea 
Psychoses with Brain Tumor 
Psychoses with Other Brain or Nervous Diseases. 
Cerebral embolism 
Paralysis agitans 
Meningitis, tubercular or other forms 
Multiple sclerosis 34 
MANUAL OF PSYCHIATRY 
Tabes Dorsalis 
Acute chorea. 
Psychoses-Intoxication 
Pathological intoxication 
Delirium tremens 
Korsakow's psychosis 
Acute hallucinosis, 
Chronic hallucinosis 
Acute paranoid type 
Chronic paranoid type 
Alcoholic deterioration 
Other types, acute or chronic 
Opium (and derivatives), cocaine, bromides, etc., alone or 
combined 
Metals, as lead, arsenic, etc. 
Gases 
Other exogenous toxins. 
Psychoses with Pellagra 
Psychoses with Other Somatic Diseases 
Delirium with infectious diseases 
Post-infectious psychosis 
Exhaustion-delirium 
Delirium of unknown origin 
Cardio-renal diseases 
Diseases of the ductless glands 
Other diseases or conditions. 
Manic-Depressive Psychoses 
Manic type 
Depressive type 
Stupor 
Mixed type 
Circular type. 
Involution Melancholia DEFINITION AND CLASSIFICATION OF MENTAL DISORDERS 
35 
Dementia Pilecox (Simple type) 
Paranoid type 
Catatonic type 
Hebephrenic type. 
Paranoia 
Paranoid State 
Psychoses, Epileptic 
Deterioration 
Clouded states 
Other conditions. 
Psychoses, Hysterical 
Psychasthenia 
Neurasthenia 
Anxiety Neuroses 
Psychoses with Constitutional Psychopathic Inferiority 
Psychoses with Mental Deficiency 
Undiagnosed Psychosis 
Epilepsy without Psychosis 
Alcoholism without Psychosis 
Drug Addiction without Psychosis 
Constitutional Psychopathic Inferiority without Psychosis 
Mental Deficiency without Psychosis 
Idiocy 
Imbecility. 36 
MANUAL OF PSYCHIATRY 
SYNOPTICAL TABLE OF THE CAUSES OF MENTAL DISEASES 
Stress of civilization 
Age 
Sex 
Education 
Habits 
Sexual life 
Climate 
Civil condition 
General 
Predisposing 
Factors 
Individual 
Inherited predisposition 
Acquired predisposition 
Repressed painful ideas 
Great emotional shock 
Worry 
Anxiety 
Sexual trauma 
Religious excitement 
Psychic 
Causes of 
Mental Diseases 
Puberty- 
Menstruation 
Pregnancy 
Childbirth 
Lactation 
Climacteric 
Senility 
Physiological 
Syphilis 
Epilepsy 
Hysteria 
Influenza 
Malaria 
Tuberculosis 
Typhoid fever 
Autointoxication 
Perverted internal secretion 
Exhaustion 
Focal infections 
Carious teeth 
Exciting Factors 
Pathological 
Alcohol 
Morphine 
Cocaine 
Laudanum 
Cannabis indica 
Various other narcotic drugs 
Arsenic 
Lead 
Mercury 
Exogenous intoxications 
Injuries to the head 
Injuries to the spine 
Injuries to the body 
Hemorrhage 
Surgical operations 
Traumatic CHAPTER III 
CAUSES OF MENTAL DISEASE 
The causes of insanity may be divided into two main classes-■ 
predisposing and exciting-as in all forms of disease. The pre- 
disposing causes are those inherent qualities of an individual's 
constitution which render him susceptible to the development 
of insanity in the presence of favorable circumstances. The 
exciting factors are those agencies or conditions which actually 
precipitate a mental disorder. The mind of an individual who 
is predisposed to insanity is like a delicately balanced scale. 
The exciting factor is comparable to a weight which disturbs 
the equilibrium of the scale. 
PREDISPOSING CAUSES 
Individual Causes.-It has been found that an inherited pre- 
disposition to insanity is present in about 50 to 90 per cent of 
all cases. Heredity, as relates to insanity, is the transmission 
of certain mental or physical qualities from the parents to the 
children which predispose them to mental disorders. Heredity 
may be divided into similar and dissimilar forms. In similar 
heredity the offspring may suffer from the same disease which 
afflicted the progenitors. In dissimilar heredity the identical 
disease is not inherited, but some other neuropathic taint is 
found in the offspring. For example, the child of an epileptic 
father may be subject to the development of hysteria or some 
form of dementia prsecox. 
Mendelian Hypothesis.-In what human characters has 
Mendelian inheritance already been proven? The most clearly 
37 38 
MANUAL OF PSYCHIATRY 
established Mendelian character in man is eye-color, in which 
brown is dominant over blue, owing to the presence or absence 
of pigment on the interior surface of the iris. Other characters 
which seem to follow Mendelian lines are: color-blindness, hair 
color and curliness, albinism, brachydactylism, syndactylism, 
polydactylism, keratosis, haemophilia, congenital stationary night 
blindness, certain forms of deaf-mutism, cataract, and Hunting- 
ton's chorea. Pathological traits seem in the main to be domi- 
nant. Retinitis pigmentosa, albinism and alkaptonuria seem to 
be recessive. Haemophilia is peculiarly "sex limited," being 
dominant in the male and recessive in the female, and is, there- 
fore, transmitted through the female, but affects the male. 
It has been agreed by the most prominent alienists that many 
forms of nervous and mental diseases are apparently hereditary. 
Among these disorders are chorea, manic-depressive insanity, 
dementia prsecox, epilepsy and feeble-mindedness. It has also 
been shown that a neuropathic constitution which renders indi- 
viduals susceptible to acute mental diseases is also an inheritable 
condition. The truth of these two statements has been thor- 
oughly established. 
In accordance with the general principle of the Mendelian 
hypothesis it would be quite possible to foretell the character 
of the progeny of certain matings. The accompanying chart 
(Fig. 2) indicates the various unions and their offspring. The 
squares represent males; the circles females; a white square or 
circle represents a normal individual; a solid black squire or 
circle indicates a neuropathic individual capable of transmitting 
neuropathic tendencies. 
I. Both parents normal, all the children will be normal. 
II. Both parents defective, all the children will be defective. 
HI. One parent being normal, but with a neuropathic taint 
from one grandparent, and the other parent defective, half of 
the children will be apparently normal, but capable of trans- CAUSES OF MENTAL DISEASE 
39 
HENDEL1AN INHERITANCE CHART. 
Fig. 2 40 
MANUAL OF PSYCHIATRY 
mitting the neuropathic constitution to their offspring, and half 
will be neuropathic. 
IV. One parent being normal and of pure normal ancestry, 
and the other parent neuropathic, all of the children will be 
apparently normal but capable of transmitting the neuropathic 
constitution to their offspring. 
V. Both parents being normal, but each with a neuropathic 
taint from one grandparent, one-fourth of the children will be 
normal and not capable of transmitting the neuropathic consti- 
tution to their offspring, one-half will be apparently normal but 
capable of transmitting the neuropathic constitution to their 
offspring, and the remaining one-fourth will be defective. 
VI. One parent being normal and of pure normal ancestry, 
and the other parent apparently normal but with a neuropathic 
taint from one grandparent, half of the children will be normal 
and incapable of transmitting the neuropathic constitution to 
their offspring, and one-half will be apparently normal but 
capable of transmitting the neuropathic constitution to their 
offspring. 
Climate.-Climate does not have a direct influence on the 
development of insanity, but the excessive heat conditions which 
occur in tropical regions so undermine the vitality of certain 
persons that they are rendered more susceptible to mental alien- 
ation. According to some authorities people who live in northern 
climates are more given to depressive forms of insanity than the 
races which live in southern zones, who seem to be more subject 
to maniacal episodes. This may, however, be due to racial 
characteristics and not to climatic conditions. 
Civil Conditions.-We find more insane among single than 
among married persons. This is perhaps due to the fact that 
the single individuals are given to greater irregularity of habits, 
especially those relating to alcohol and sexual practices. Yet CAUSES OF MENTAL DISEASE 
41 
it must be borne in mind that many individuals are unmarried 
because of neuropathic tendencies and sexual abnormalities. 
Civilization.-The stress of modern life which has rendered 
more keen and acute the struggle for existence and which has 
created a taste for liquors, drugs, idleness and debauch, has also 
favored the increase of mental disorder. The great centers of 
population, with their hurry, excitement, worry and unnatural 
modes of living, contribute to the population of our hospitals for 
the insane in a far greater ratio than do the rural districts. 
Extreme isolation, however, has been found to be associated 
with depressive types of mental disorder. 
Education.-Excessive study or an ill-balanced mode of 
education has a tendency to give opportunity to the expression 
of inherited nervous defect. It must be borne in mind that 
although the educated classes furnish but a relatively small per- 
centage of patients in public institutions for the psychopathic, 
the number of patients from these classes is far greater in private 
sanitariums. 
EXCITING CAUSES 
Psychic Causes.-Great mental shock, long continued worry, 
anxiety, excessive grief, mental sexual trauma, all exert an influ- 
ence for the development of insanity. These agencies must not 
be overestimated, however, for they are sufficient, usually, to 
produce mental alienation only when they act upon fertile and 
predisposed soil. 
Physiological Causes.-The physiological stress which at- 
tends puberty (both sexes included), menstruation, pregnancy, 
childbirth, lactation and the menopause are sometimes attended 
by mental disturbances which frequently result in more or less 
permanent mental disorders. 
Pathological Causes.-Certain of the infectious diseases are 
frequently followed by a train of mental symptoms. This is 42 
MANUAL OF PSYCHIATRY 
particularly true of influenza, typhoid fever and malaria. Syphi- 
lis may be attended by psychotic symptoms at any stage of its 
course. Approximately 25 per cent of all admissions to institu- 
tions are due to the direct and indirect influence of syphilitic 
disease. 
The post-febrile insanities may be due to exhaustion or 
nervous fatigue which attend them or to the disastrous effects 
of the infectious agent on the central nervous system. Perhaps 
it would be more correct to say that the febrile insanities are 
due to the effects of both factors. 
Traumatic and Surgical Causes.-Some cases of insanity 
have a more or less well-defined onset dating from some injury 
to the head or spinal column. Great loss of blood attended by 
exhaustion acts as an exciting cause. Insolation and electric 
shock often contribute in a measure to mental disease. It has 
been established by clinical experience that operations on the 
eye or genitalia, chronic irritating conditions due to uncared-for 
surgical needs, such as lacerations of the generative organs in 
the female, impacted teeth, cord and brain tumors, are exciting 
and causal factors for the production of mental disorders. 
Toxic Causes.-Under the head of toxic causes we have two 
varieties. First, the exogenous class, or those deleterious sub- 
stances which are taken into the body. Within this class we 
may include alcohol, cocaine, morphine, cannabis indica, chloral, 
and other drugs. Arsenic, mercury and other metallic drugs 
have been agents in producing psychoses. Second, the endoge- 
nous class, composed of those poisons which originate within 
the body. This class exerts its untoward influence by deranging 
the body metabolism and poisoning the body fluids. Disturb- 
ances of the function of the endocrine glands, the testicles or 
the ovaries, and chronic focal infections such as diseased tonsils, 
carious teeth and similar sources of pus dissemination, are ex- 
amples of this type. Conditions of autointoxication develop CAUSES OF MENTAL DISEASE 
43 
from a function of the liver, kidneys and intestines to such an 
extent that the general nervous system may be markedly 
affected. 
GENERAL CONSIDERATIONS 
It must be remembered, however, in considering the causes of 
insanity, that none of them act singly or alone. Alcohol, syphilis 
and bad heredity are often found in combination. An individual 
with a stable nervous system may withstand trauma, but an 
individual with a poorly synthesized nervous organization may 
develop psychotic symptoms following the slightest degree of 
injury. All factors-psychic, physiological, pathological, toxic 
and traumatic-which may be active in the possible production 
of insanity in a given case, must be carefully studied in conjunc- 
tion with the effects of heredity and environmental influences. CHAPTER IV 
SYMPTOMS OF MENTAL DISORDERS 
The symptoms of mental disorder may be divided into two 
classes, psychic and somatic. The mental symptoms may be 
divided into disorders of intellection, disorders of emotion and 
disorders of volition. The somatic symptoms may be divided 
into physical and neurological groups. 
DISORDERS OF INTELLECTION 
Disorders of Consciousness.-First among the disorders of 
intellection are the disturbances of consciousness: 
1. Clouding of Consciousness. 
2. Confusion. 
3. Delirious States. 
4. Stuporous States. 
5. States of Somnolence. 
6. Comatose States. 
7. Syncope. 
8. Lethargy. 
9. Dream States. 
Clouding of Consciousness.-This is a condition of mind in 
which the perceptions of environment are faulty, owing to a 
dulling of perception; a defect in the mechanism of sensation 
which gives the brain but an imperfect visualization of external 
stimulation. Consciousness may be clouded by alcohol or drugs,, 
or it may be affected by endogenous poisons circulating in the 
blood. Disturbances of consciousness may be slight or extreme. 
44 SYMPTOMS OF MENTAL DISORDERS 
45 
Confusion.-In states of confusion the patient is in a daze. 
He imperfectly perceives his environment. His voluntary atten- 
tion is markedly impaired. Conversation is incoherent and 
disconnected. The speech is fragmentary and contradictory. In 
this condition the patient has hallucinations, delusions and illu- 
sions. He is unable to make a decision and is quite helpless 
because of this state of indecision. 
Delirious States.-In this condition there is rapid change of 
the emotions. The patient is alternately happy, elated, de- 
pressed, irritable and apprehensive. His speech is rambling and 
incoherent and is usually concerned with his feelings. There is 
great restlessness. The patient picks at the bedclothes and 
fumbles with objects within his reach. Delusions and illusions 
of a transient character are noted. There is usually a history 
of physical illness in these cases, or the patient is found to be 
ill. These delirious states are generally accompanied by eleva- 
tions of temperature. 
Stuporous States.-These are conditions which attend mental 
disorders, notably in dementia prsecox and in the depressive 
phase of manic depressive insanity. In the milder types of 
stupor consciousness is not usually disturbed. It remains clear, 
the patient being aware of what is going on about him. Yet he 
remains in a state of more or less cloudiness, apparently taking 
no cognizance of his environment. In some forms of stupor 
consciousness is greatly clouded. The patient is disoriented as 
to time, place and persons, and all voluntary motion is abolished. 
States of Somnolence.-Somnolence is a condition of incom- 
plete sleep, from which a patient may be roused by energetic 
stimulation. As soon as the stimulation subsides the patient 
falls again into the condition of somnolence. 
Comatose States.-Coma is a state of complete loss of con- 
sciousness from which the patient cannot be aroused even by the 
most powerful stimulation. It is attended by stertorous breath- 46 
MANUAL OF PSYCHIATRY 
ing, loss or impairment of sphincteric control, and cyanosis of 
the face. This condition occurs in poisoning from alcohol, mor- 
phine, cocaine, chloral and veronal, and in apoplexy, fracture of 
the skull, meningitis, diabetes, Bright's disease, eclampsia, syphi- 
lis and brain tumor. 
In all cases of coma the urine should be immediately examined 
and the patient given a careful general examination. In coma 
the pupillary, corneal, skin and tendon reflexes are diminished 
or abolished. 
The term coma is often very loosely used and applied to the 
various types of more or less profound loss of consciousness. 
Several types of coma have been differentiated. They are as 
follows: 
Opium Coma.-Pulse.-At first slow and full; becomes very 
rapid and thready. 
Respiration.-Noisy at first; slow; finally from three to 
twelve per minute; then irregular. 
Temperature.-Normal, usually, with a rise before death. 
Pupils.-Pinpoint type; miotic; no light reaction. Often 
dilate before death. 
Reflexes.-Abolished or diminished. 
Face.-Dusky; cyanotic. 
Extremities.-Usually cold and cyanotic. 
Odor.-May have odor of opium or paregoric. 
Urine.-May show traces of opium or its alkaloids. 
The coma may be of a mild, moderate or profound type. If 
not profound, the patient may be able to answer questions 
shouted at him and to respond to mild stimulation. In profound 
coma there is no response and the condition often ends in death. 
Alcoholic Coma.-Pulse.-At first rapid and full, becoming 
thready and feeble. 
Respiration.-Noisy and full, later becoming rapid and 
shallow in fatal cases. symptoms of mental disorders 
47 
Temperature.-Usually normal. May be sub-normal. In 
fatal cases it is sub-normal. 
Pupils.-May be dilated, irregular in outline, unequal in 
size-no uniformity. 
Reflexes.-Usually normal. May be irregular or absent. 
Coma is often associated with organic disease of the brain. 
Face.-At first flushed and then pale. In chronic alcoholics 
there is a flushed or cyanotic face, marked by dilated capillaries. 
Extremities.-Cold, covered with a clammy perspiration. 
Odor.-Odor of alcoholic liquor on the breath. 
Urine.-Usually negative. 
Epileptic Coma.-Pulse.-Usually full and strong. Rate 
increased in status. Irregular, rapid and feeble. 
Respiration.-Rapid at first, then decreased, then stertorous. 
Temperature.-Normal or slightly above normal. In status 
it may be several degrees above normal. 
Pupils.-May be contracted, dilated, and may not respond 
to light. Cornea is insensitive. 
Reflexes.-Diminished or absent. 
Face.-First cyanotic, then pale, later suffused. Head turned 
to the side. Bloody saliva present. Tongue and cheeks bitten; 
scars on face. 
Extremities.-Warm; hands purple. 
Odor.-There is no characteristic odor. 
Urine.-Loaded with phosphates and other organic material. 
Sphincteric Control.-Often lost, especially of the bladder. 
Previous History.-Usually a history of epileptic or convul- 
sive attacks. 
The coma is usually of short duration, except in cases of 
status, where it may last from a few hours to two or three days. 
Hysterical Coma.-Pulse.-Normal. 
Respiration.-Spasmodic. Violent movements of the chest 
are often noted. Never stertorous. 48 
MANUAL OF PSYCHIATRY 
Temperature.-Normal. 
Pupils.-Respond to light. Cornea is insensitive at times. 
Reflexes.-Present. May be slightly increased. 
Face.-Normal. Color, pale; occasionally cyanotic because 
the patient unconsciously holds his breath. 
Extremities.-Negative. 
Odor.-No characteristic odor. 
Urine.-Pale, limpid, excessive. 
Sphincteric Control.-Not lost. 
Previous History.-History of emotional disturbance; con- 
vulsive attacks. 
The coma is of short duration and never profound. The 
patient can be restored to consciousness by shouting, stimulation 
by pin pricks, a dash of cold water or a spray of ether. 
Uremic Coma.-Pulse.-Rapid; full. High tension at first, 
then irregular, thready and feeble. 
Respiration.-Full, deep, increased in rate, then becoming 
slow and irregular. Cheyne-Stokes breathing. 
Temperature.-First normal, then sub-normal. Occasionally 
elevated just at death. 
Pupils.-No uniformity. Pupils may be normal, contracted, 
or widely dilated. More often they are contracted. 
Reflexes.-Diminished or in abeyance. 
Face.-Cyanotic, then pale. Usually edematous. 
Extremities.-Edematous, cyanotic, rigid. 
Odor.-Breath offensive-odor of urine. 
Urine.-Contains albumen and casts, epithelial cells and 
ammoniacal salts. 
Sphincteric Control.-May be lost. 
Previous History.-Headache, dizziness, vertigo, choked disc. 
Apoplectic Coma.-Pulse.-Full, strong, growing weaker with 
the length of coma. 
Respiration.-Slow, stertorous, often Cheyne-Stokes. SYMPTOMS OF MENTAL DISORDERS 
49 
Temperature.-Usually above normal. 
Pupils.-Do not react to light. Unequal in size, usually 
dilated. Conjugate deviation of the eyes. 
Reflexes.-Unequal, increased or absent on the paralyzed 
side, according to the location of the lesion. 
Face.-Paralyzed on one side; drooping of the angle of the 
mouth; absence of wrinkles; flapping of the cheek. 
Extremities.-Paralysis in one or both extremities; flaccidity 
of the paralyzed side; hemiplegia. 
Odor.-No characteristic odor of the breath. 
Urine.-Negative, usually. May show casts, albumen, granu- 
lar cells. 
Sphincteric Control.-Usually retained. 
Previous History.-Patient past fifty years of age. Evidence 
of arteriosclerosis. Coma abrupt. Signs of cerebral arterio- 
sclerosis. 
Paretic Coma.-Pulse.-Rapid, feeble, thready. 
Respiration.-Shallow; rapid. 
Temperature.-Normal or elevated. 
Pupils.-Rigid, as a rule. May respond slowly to light. 
Unequal in size and irregular in outline. 
Reflexes.-May be increased, diminished, absent or unequal. 
Face.-Masklike; lines effaced; pale. 
Extremities.-Warm or cold, depending on the general con- 
dition of the patient. Often marked with syphilitic scars. 
Odor.-No characteristic odor of the breath. There may be 
odor about the patient due to the fact that he is untidy and 
soils himself. 
Urine.-May show casts, albumen and ammoniacal salts. 
Sphincteric Control.-Lost. 
Previous History.-Often a history of syphilis. Positive 
Wassermann of the blood and spinal fluid. History of the pres- 
ence of the neurological signs of paresis. Syncope. Convulsions. 50 
MANUAL OF PSYCHIATRY 
Diabetic Coma.-Pulse.-Full; strong; often bounding. Later 
weak and thready. 
Respiration.-Normal, deep, or frequently increased. 
Temperature.-Usually subnormal. 
Reflexes.-Tendon reflexes present. 
Face.-Pale. 
Extremities.-Of the same temperature as rest of body; 
usually subnormal. 
Odor.-Breath has sweetish, fruity odor. 
Urine.-Contains sugar. 
Sphincteric Control.-May or may not be lost. 
Previous History.-History of the classical signs of diabetes. 
Syncope.-Syncope is a temporary suspension of conscious- 
ness due to cerebral anemia. 
Lethargy.-Lethargy is a condition of drowsiness of mental 
origin. This condition follows mental and physical shock. It is 
associated with muscular relaxation and tremor of the eyelids, 
isolated movements of groups of muscles or a limb, and a 
condition of incomplete anesthesia of the body. There is usually 
but slight change in the appearance of the skin. 
Dream States.-In these conditions there is a defect of con- 
sciousness in which the environment is imperfectly perceived. 
The condition that exists just before passing from consciousness 
into sleep or waking out of sleep into consciousness is typical 
of the dream state. 
Orientation.-When consciousness is very much disturbed, 
orientation will be defective. 
Spatial Orientation.-When an individual fully appreciates his 
position with reference to persons, to objects, to buildings, to 
cities, etc., he is oriented in the spatial sphere. 
Personal Orientation.-When a person is fully conscious of 
his own identity and the identity of others about him, he is 
personally oriented. SYMPTOMS OF MENTAL DISORDERS 
51 
Temporal Orientation.-When a subject knows the time of 
day, day of the week, the month and the year, he is oriented in 
the temporal sphere. An individual may be disoriented in one 
or all of the spheres. He may be partially oriented in all the 
spheres. Disturbances of orientation are common in mental 
diseases. 
Hallucinations.-An hallucination is a false perception sub- 
jective in character, not based on an external reality; i. e., an 
individual believes he sees a picture on the wall, when there is 
nothing to be mistaken for a picture; human voices are thought 
to be heard by the patient when no sounds are present. Hal- 
lucinations of the general feelings or of the special senses are 
common. They may be bilateral when the sense organs are 
double, as in the case of the eye or ear. The hallucinations may 
be unilateral when affecting one organ only, or the hallucination 
may be different in each organ. There are as many varieties of 
hallucinations as there are sense organs. They are- 
Hallucinations of Sight 
Hallucinations of Hearing 
Hallucinations of Taste 
Hallucinations of Smell 
Hallucinations of Touch 
Hallucinations of Feeling (Somatic) 
Illusions.-An illusion is a perverted perception, objective in 
character, occurring when a sensory stimulation is misinter- 
preted. For example, a picture on the wall is thought to be a 
telephone. A peculiar taste in the mouth is thought to be poison. 
A cane on the floor is interpreted to be a snake. 
Delusions.-A delusion is a false belief. Such beliefs are 
sometimes entertained by sane persons. A delusion of the insane 
is a false belief due to disease and is retained by its possessor 
in the presence of physical demonstration or evidence that it is. 52 
MANUAL OF PSYCHIATRY 
false. Many false beliefs exist among normal individuals. The 
negro often believes in ghosts and witchcraft and other super- 
stitions. A neurasthenic class believes in Christian Science and 
kindred doctrines. These errors of belief, however, are not to 
be confused with insane delusions whose origin and consequences 
bear a pathological stamp. Delusions may be divided arbi- 
trarily into a number of classes according to their characteristics. 
The following classification will serve the practitioner's needs. 
A systematized delusion is one which is supported by its pos- 
sessor with more or less logical argument. This form of delusion 
is usually intimately associated with the whole of consciousness 
and therefore exerts a powerful influence on the conduct of its 
possessor. 
An unsystematized delusion is one that is not supported by 
argument but merely stated by its possessor to be a fact. This 
type of delusion is most common and is found in the majority 
of mental disorders. 
A fixed delusion is one more or less permanent in character 
and is usually systematized. 
For practical purposes delusions may be classified as follows: 
Delusions of Persecution 
Delusions of Suspicion 
Delusions of Depression 
Delusions of a Grandiose Nature 
Delusions of an Erotic Nature 
Delusions of a Religious Nature 
Delusions Regarding Personality. 
Memory.-In most of the psychoses memory shows some 
defect. Loss of memory may be partial or complete for a short 
space of time. It may be periodic, progressive, total, permanent 
in character, for recent and remote events, for the particular, 
for the general, for the simple and the complex. SYMPTOMS OF MENTAL DISORDERS 
53 
Amnesia.-Loss of memory is termed amnesia. 
Retrograde Amnesia.-This type of amnesia is usually due to 
illness or injury and has a fairly well-defined beginning and 
ending. 
Anterograde Amnesia.-In this type of amnesia the patient is 
unable to retain memories of experiences. It is a continuous 
process and is encountered in states of dementia. 
Hyperamnesia.-In certain exalted and euphoric states of 
consciousness the power of memory is apparently increased. 
Paramnesia.-This is a term applied to that condition of 
mind which exists when a person believes that he remembers 
events or circumstances which never happened. This condition 
is also termed retrospective falsification. 
Alcoholic Amnesia.-This condition has been observed in per- 
sons who are chronic users of alcoholic beverages. Persons so 
afflicted may appear to be in a normal state of mind, but in 
these states of amnesia acts are committed which are not recalled 
after consciousness has been fully recovered. 
Incoherent Ideation or Flight of Ideas.-When this condi- 
tion obtains the patient is unable to express concisely a definite 
or goal idea, because there are other ideas rushing into con- 
sciousness, "all seeking for expression but none gaining the 
mastery." As a rule the conversation is full of irrelevant and 
disconnected statements, as "I am a Mason," "I saw a man," 
"The tree is," "Do you belong to the church?" "How do you 
like the fish?" 
Initiation 
of idea 
Coal 
not reached 
Circumstantiality.-In this condition of mind the goal idea 
is finally reached, but the conversation is full of unimportant MANUAL OF PSYCHIATRY 
54 
detail that is not related to the subject. Circumstantiality is 
common in the senile and in the illiterate. 
Goal idea 
J reached 
Initiation 
of idea 
Aprosexia.-This is a term applied to the condition of 
inability to concentrate the mind upon a subject for any length 
of time. When this condition persists it is regarded as a symp- 
tom of mental deterioration. 
Hyperprosexia.-This is the name given to the mental con- 
dition that exists when the mind is occupied by one thought or 
idea to the exclusion of others. 
Disorders of Personality.-Many patients frequently believe 
that they are other persons than themselves. It is common to 
find, in hospitals for the insane, patients who believe themselves 
to be celebrities of history, as Christ, Napoleon, Moses, or other 
noted personages. 
Depersonalization.-This is a term applied to the condition 
of mind in which the patient denies the existence of his person- 
ality or believes that certain organs of his body are missing or 
that they belong to other persons or to animals. 
Multiple Personality.-This is a state of mind in which the 
patient seems to have a double or multiple consciousness. These 
apparent personalities are usually separated from one another by 
complete amnesia, and the possessor is not aware of his dual 
personality. 
Ganser's Symptom.-This peculiar symptom, observed by 
Ganser, is one in which the patient gives approximately correct 
answers to questions. This symptom occurs very frequently in 
hysteria, in states of constitutional inferiority and in dementia SYMPTOMS OF MENTAL DISORDERS 
55 
praecox. If the patient displaying this symptom were asked 
what is nine times nine, he would likely say it was eighty or 
eighty-three, or that four times ten is thirty-eight, or five times 
six is twenty-nine. If the question concerned orientation in the 
temporal sphere he would be likely to say that the year is 1921 
when he should have said 1922. If asked the day of the week 
he is likely to mention a day later or earlier than the actual day. 
Obsessions.-These are persistent ideas that come into con- 
sciousness, over which the patient has no control. There are 
many varieties of obsessions and they very frequently occur in 
apparently normal individuals. Obsessions may be divided into 
the following classes: 
Mysophobia, Fear of Dirt 
Claustrophobia, Fear of Enclosed Places 
Pyrophobia, Fear of Fire 
Agoraphobia, Fear of Open Spaces 
Sitophobia, Fear of Food 
Syphilophobia, Fear of Syphilis 
Metallophobia, Fear of Metals. 
There are as many types of phobias as there are varieties of 
fear. 
Retardation of Thought.-Initial Retardation.-Initial re- 
tardation is that condition in which the thinking processes are 
set in motion slowly. 
Executive Retardation.-Executive retardation exists when the 
thought or action, once having been expressed or commenced, 
is slowly and deliberately performed. 
Paralysis of Thought.-In this condition all mental processes 
are practically inert, as in the terminal stages of general 
dementia. 
Blocking of Thought.-Thought block is noted in dementia 
praecox. The patients explain that they find great difficulty in 56 
MANUAL OF PSYCHIATRY 
expressing themselves because "the avenues of thinking are 
obstructed." 
DISORDERS OF EMOTION 
All special qualities of the mind, such as egoism, pride, malice, 
philanthropy, hatred, love, anger, are subject to abnormal 
expression or repression in mental disorder. The following 
disorders are the ones most commonly exhibited: 
Pathological Elation.-This condition is frequently seen in 
the insane. It is a state of happiness or satisfaction not in 
harmony with the condition of the patient or his environment. 
Marked Depression.-This is a pathological state of anxiety 
and unhappiness that is not in accord with the physical condition 
of the patient or his environment. 
Emotional Deterioration.-This is a pathological condition 
in which the emotions fail to respond to those stimuli which 
would in health arouse a reaction. The death of a relative, the 
loss of a fortune, or a disagreeable environment have but little 
influence on a person so afflicted. 
Mercurial Disposition.-This condition is often observed in 
hysteria, in some forms of dementia preecox and in senile states. 
Patients so affected are given to laughter, tears and excessive 
anger. A rapid change of their minds takes place within the 
space of a few minutes, under the most trivial stimulation. 
Morbid Anger.-This condition is often noted in the insane 
and the feebleminded. The slightest trifles are often sufficient 
to stir them to excessive and transient outbreaks of temper that 
sometimes lead to crime. 
Emotional Poverty.-This condition is noted especially in 
dementia praecox. There is a marked diminution in such quali- 
ties of the mind as love, honor, altruism, charity and kindred 
sentiments, under stimuli which would be adequate to provoke 
such sentiments in the sane. SYMPTOMS OF MENTAL DISORDERS 
57 
DISORDERS OF VOLITION 
Decreased Psychomotor Activity.-In this condition there 
is a decrease of all motor activity. The patient thinks and acts 
in a slow, deliberate manner. 
Increased Psychomotor Activity.-In this state the patient 
thinks rapidly but usually incoherently. He is restless, con- 
stantly active, and his endeavors are usually without purpose 
and definite accomplishment. 
Negativism.-This is a condition of mind in which the patient 
endeavors to do the opposite of that which is asked of him. He 
even opposes the normal physiological desires. In the active 
form of this trouble he offers resistance when compelled to act. 
Suggestibility.-In this condition the patient's volition is so 
defective that he is thereby rendered abnormally susceptible to 
suggestion. Often his limbs may be placed in various uncom- 
fortable positions, in which they will remain until the force of 
gravity and muscular fatigue draw them down. This condition 
is known as flexibilitas cerea. 
Impulsions.-This is the term used to express that mental 
condition in which the patient feels irresistibly impelled to do 
certain acts, usually of a disagreeable nature. 
Compulsions.-This is a condition similar to impulsion. The 
patient feels compelled to do certain definite, foolish acts. When 
he resists the inclination he experiences a sensation of exhaustion 
and dizziness. With the completion of the compulsive act these 
symptoms disappear. 
Stereotypy.-Stereotypy is the continued repetition of sense- 
less acts. It occurs in three forms. 
Stereotypy of Speech, or Echolalia.-This is the constant 
repetition of certain words or phrases. The term verbigeration 
is also applied to this mannerism. 
Stereotypy of Movement, or Echopraxia.-The repetition of 58 
MANUAL OF PSYCHIATRY 
senseless movements. The term mannerism is also applied to 
this condition. 
Stereotypy of Attitude.-This term is applied to that condition 
in which the patient maintains certain bodily attitudes. The 
patient usually resists any efforts made to change these positions 
or attitudes. 
Perseveration.-This is the constant repetition in writing or 
speech of some word or phrase in response to a question. 
Complex.-The average individual has his content of mind 
arranged in a fairly orderly manner. He groups certain ideas 
about objects in a more or less definite way. When the word 
"automobile" is brought to his attention he has a constellation 
of ideas or a grouping of perceptions concerning an automobile. 
He thinks of the size of the machine, its color, shape, weight, 
horsepower and mechanism. The higher the mental development 
of an individual, the better his ideas are grouped and arranged. 
The contrary is true of those poorly endowed mentally, or with- 
out education. All ideas are more or less pleasurable or painful, 
according to their character, and the quality of feeling or 
emotion concerning a group of perceptions is the mental sub- 
stance that binds it together. Every group of ideas is erected 
upon a background of feeling or emotion. Every individual has 
had, during his life, experiences which are more or less painful, 
and he usually tries to push these painful conceptions or groups 
of ideas into the background, out of consciousness. After a 
group of ideas has been pushed into the background, out of the 
main body of consciousness, it continues to have an independent 
existence, and between it and the main body of consciousness 
there is established a mental conflict of which the individual may 
not be aware. In other words, there is a cleavage of conscious- 
ness or disassociation of consciousness. The conflict between the 
main body of consciousness and the disassociated group of pain- 
ful ideas seeks an avenue of expression, of which the individual SYMPTOMS OF MENTAL DISORDERS 
59 
may be unconscious, and there may develop, by reason of this 
vicarious expression, a neurosis or psychosis. Patients come to 
the psychiatrist many times with very queer and apparently 
unexplainable symptoms, and if no organic or functional disease 
can be discovered as a basis of the psychosis or neurosis, it is 
necessary for the psychiatrist to discover whether or not there 
is a mental conflict, or what has been termed a submerged 
complex or disassociated state. 
The identification of this complex is often difficult, for the 
complex itself, or the group of painful ideas, is disguised in 
peculiar forms of symptoms or symbols. The following may 
serve as an illustration: 
During youth an extremely religious individual, under the 
stress of a great cosmic urge, indulged in illicit sexual inter- 
course. After the act was committed, owing to the individual's 
moral training, her conscience severely criticized her action. She 
attempted to repress the memory of the illicit intercourse and to 
press it into the background, out of the main body of conscious- 
ness. The submerged complex or the repressed idea sought for 
expression. The individual's conception of morality and respect 
for moral conventions tried to keep the painful idea from coming 
into the foreground, and as a result of the struggle between the 
sinful memory and the attempt of conscience to repress it, there 
developed a marked state of mental conflict. Finally the painful 
idea succeeded in gaining the mastery of the situation, so to 
speak, but came into consciousness in a disguised manner, in 
this instance in the form of an intolerance of anything that had 
to do with sexual life or experiences, and the individual became 
exceedingly prudish. 
In another case that came under the observation of the author 
a young woman of extreme piety indulged in periodic sprees of 
wine-drinking, cigarette-smoking and masturbation, the result of 
which was a highly neurotic state. By a process of psycho- 60 
MANUAL OF PSYCHIATRY 
analysis it was discovered that the young woman had at the 
age of fourteen indulged in illicit intercourse. All through 
adolescence this idea was extremely painful to her, and a great 
effort was made to push all ideas of sexual matters into the 
background. The young woman became a religious zealot and 
took advantage of every possible opportunity to attend divine 
worship, in an effort to crowd out of consciousness the repressed 
erotic desire which the first sexual experience had awakened. 
For a month or six weeks at a time the patient was able to 
restrain her sexual impulses by faithful church attendance and 
the reading of religious literature to the exclusion of all else. 
Periodically the repressed idea would overcome the efforts of a 
great portion of conscious restraint, and the young woman would 
then indulge privately in alcoholic sprees, cigarette-smoking and 
excessive masturbation. In this way her sexual desires were 
vicariously gratified and her reputation for chastity preserved. 
THE SOMATIC SYMPTOMS OF MENTAL DISORDERS 
GENERAL PHYSICAL STATUS 
State of Nutrition.-In melancholia, in states of delirium and 
in the third stage of paresis there is generally great loss of 
weight attended by anemia of the. skin and mucous membranes. 
In chronic alcoholism there may or may not be an increase of 
weight, associated with reddening of the face and dilatation of 
the facial capillaries. In arteriosclerotic insanity and senile 
dementia there is generally a wasting of the body tissues. In 
dementia we may have a disturbance of the vasomotor system. 
There is lividity and cyanosis of the extremities. Occasionally 
we find the condition of dermatographia. This, however, may 
occur in perfectly healthy individuals. Bed sores are common 
in general paresis. Among the insane we find disturbance of 
metabolism due to imbalance of the endocrine glands which 
produce the various well-known conditions of myxedema, giant- SYMPTOMS OF MENTAL DISORDERS 
61 
ism and eunuchoidism. We also find the anatomical stigmata 
of degeneracy, such as deformities of the cranium as regards size 
and shape, asymmetry of the face, Mongolian development of 
the face, inferior and superior prognathism, cleft palate, hare- 
lip and dental anomalies, evidences of inherited syphilis, Hutch- 
inson's teeth, rhagades about the mouth, Morel and Darwinian 
ears, polydactylism, syndactylism, brachydactylism and mal- 
formation and lack of development of the genital organs. 
Internal Organs.-Diseases of the heart are common among 
the insane and especially common in the syphilitic psychoses. 
Aortic aneurism and aortitis frequently attend paresis. 
Pulse.-Bradycardia is common in states of mental depres- 
sion, coma and stupor and in organic diseases of the brain and 
spinal cord. A rapid pulse is observed in neurasthenia, hysteria 
and psychasthenia. In arteriosclerotic dementia there is likely 
to be an increase in the blood pressure. 
Respiration.-In hysteria there is often an increase in the 
respiratory rate, and conditions resembling asthma. Owing, to 
the convulsive movements of the chest in paroxysms of hysteria, 
the respiration is often heaving, jerking and irregular. 
Vomiting.-Vomiting frequently attends brain disease. It is 
quite common in tumor of the cerebellum. The gastric crises 
of tabes and paresis are well known. Regurgitation of the food 
is a frequent symptom of hysteria. There is usually no nausea 
attendant upon hysterical vomiting. 
Anorexia.-This is common in diseases attended by mental 
depression and hysteria. It may be of such intensity as to lead 
to the refusal of food. 
Bulimia.-This is an excessive and unnatural appetite for 
food. It is frequently exhibited in maniacal and demented states, 
and is very common in paresis. 
Meteorism.-This condition is quite often observed in the 
feeble-minded and in demented and hysterical patients. MANUAL OF PSYCHIATRY 
62 
Changes of Temperature.-Fluctuations in the body tem- 
perature are encountered very frequently in mental diseases. 
Transient conditions of pyrexia are frequent in paresis, infectious 
psychoses, abscess of the brain, apoplexy, following epileptic 
convulsions, and in status epilepticus. 
NEUROLOGICAL SYMPTOMS 
Only the most important neurological symptoms associated 
with the psychoses have been mentioned, and for full detail of 
their mechanism the student is referred to texts on neurology. 
Pupillary Disturbance.-The average pupil is from 3-5 mm. 
in diameter. Irregular and unequal pupils are found in general 
paresis, tabes and the syphilitic psychoses. Inequality of the 
pupils may be observed, however, in persons of normal health, 
but the inequality in such instances does not usually exceed % 
mm. In chronic morphinism the pupil is usually very much 
contracted (the pin-point pupil). Very frequently the Argyll- 
Robertson pupil is observed in paresis and in the syphilitic 
psychoses as well as in tabes dorsalis. The student should 
familiarize himself with the proper methods of examining the 
pupils, and the use of the ophthalmoscope. 
Iridoplegia.-Rigidity of the pupil always suggests the pres- 
ence of organic disease of the nervous system and occurs 
most frequently in paresis, tabes and the syphilitic psychoses. 
Sluggishness of the pupillary reaction may be a premonitory 
symptom of iridoplegia. 
Amaurosis.-This condition is sometimes psychogenic. It is 
occasionally found in hysteria. Psychogenic blindness may come 
on gradually or suddenly and may disappear in the same 
manner. Blindness appears in organic disease of the visual 
apparatus and the optic tracts, as in optic atrophy, occurring 
in tabes and in albuminuric retinitis. SYMPTOMS OF MENTAL DISORDERS 
63 
Concentric Constriction of the Visual Field.--This symp- 
tom is noted in organic disease of the brain, choked disc, optic 
atrophy, in hysteria, and occasionally in neurasthenia. 
Dysarthria.-Dysarthria is usually found in paresis. With 
this disease there is generally a twitching of the muscles of the 
mouth and a wrinkling of the facial muscles in general. In 
hysteria is often found a condition of stammering. Scanning 
speech is observed in disseminated sclerosis. Plateau speech is 
observed in epilepsy. In this condition the conversation is car- 
ried along in a monotone, with an occasional elevation of the 
voice. In the aged there is often a stumbling and reduplication 
of syllables and transposition of letters and words. This also 
occurs in paresis. 
Aphasia.-Aphasia is a defect shown by the loss of power to 
express words or ideas in speech, writing or symbols, or to 
comprehend spoken or written language. The type of aphasia 
depends on the location of the lesion, which is somewhere in the 
cortex of the left hemisphere in about the speech centers or their 
connecting tracts. More than thirty forms have been described, 
according to the character of the clinical symptoms. Aphasia 
occurs occasionally in infectious diseases that are attended by 
meningeal involvement and in cases of trauma to the cortex 
from falls or blows on the head. It is most frequently encoun- 
tered in the organic dementias and the syphilitic psychoses. 
Ageusia.-Ageusia is the loss of the sense of taste. This 
condition is often found in the organic dementias and in 
neurosyphilis. 
Anosmia.-This is the loss of the sense of smell and is usually 
found associated with ageusia; also in local disease of the nasal 
tract. 
Asterognosis.-Asterognosis is the inability to recognize, 
when the eyes are closed, common objects which may be placed 
in the hand. It is due to organic disease in the association tracts 64 
MANUAL OF PSYCHIATRY 
of the cortex and to disease of the optic thalamus. It is fre- 
quently found in syphilitic psychoses and in paresis. 
Apraxia.-Apraxia is a loss of the ability to obey simple com- 
mands, such as picking up a book or shutting a door, when no 
condition of ataxia or paralysis is present. This condition is 
noted in the syphilitic psychoses, in arteriosclerotic dementia 
and in Alzheimer's disease. 
Paralexia.-In this condition the patient leaves out words or 
inserts wrong words while reading from the printed page. It 
occurs in the organic dementias, particularly paresis. Patients 
displaying this symptom are often able to read but cannot 
express what they have read. 
Agraphia, Paragraphia, Dysgraphia.-In agraphia and para- 
graphia there are errors in writing due to transposition of letters 
or words, and due to forgetfulness on the part of the patient. 
Dysgraphia is due to the inability to write because of tremors 
or ataxia and corresponds to dysarthria. These conditions are 
found in organic dementia and in paresis. 
Convulsions, Spasms.-Spasms and convulsions of certain 
groups of muscles are observed in meningitis and in paresis. 
General convulsions are observed in epilepsy, hysteria and 
paresis. They will be described in the symptomatology of the 
diseases in which they occur. 
Tremors.-Tremors are due to fatigue, emotional disturbance, 
intoxications, goitre and organic disease of the nervous system. 
They occur in senile dementia, paresis, paralysis agitans and 
disseminated sclerosis. In hysteria and neurasthenia coarse 
tremors of the body, limbs and hands and fine tremors about the 
face are observed. 
Reflexes.-Superficial.-These are the corneal, plantar, ab- 
dominal and cremasteric. In testing the corneal reflex the cornea 
may be lightly touched with a hair. It is absent in coma, in 
narcosis and in diseases of the Gasserian ganglion. It is often SYMPTOMS OF MENTAL DISORDERS 
65 
absent in hysteria. The plantar reflex is elicited by stroking the 
sole of the foot gently with the finger or a pencil or other instru- 
ment. As the result of this stimulation there is a flexion of all 
the toes. If there is disease in the pyramidal tracts there will 
be an extension of the great toe, while the other toes may remain 
passive or be flexed toward the dorsal surface of the foot. In 
individuals over three years of age the Babinski reflex is an 
indication of organic nerve disease. It is occasionally observed 
in paresis and the syphilitic psychoses. The other superficial 
reflexes are of little value in the diagnosis of mental diseases. 
Patellar Reflex.-This reflex should always be tested. It is 
increased in neurasthenia and nervous states and in nervous 
individuals under conditions of fear and fright. It is absent in 
well-developed cases of tabes. It is often increased, unequal or 
absent in paresis and the syphilitic psychoses. 
Sphincteric Control.-Control of the bladder and the rectum 
is disordered in tabes, paresis and the syphilitic psychoses. 
Incontinence may occur during an epileptic convulsion. Enuresis 
is the involuntary reflex evacuation of the bladder which occurs 
in individuals of constitutional inferiority and in children. 
Headache.-Cephalalgia.-This may be diffused or localized; 
may appear as a tight band around the head; may or may not 
be attended by vomiting. It occurs in neurosyphilis, brain 
tumor, meningitis, abscess, arteriosclerosis, uremia, anemia, 
drug poisoning, neurasthenia, hysteria and migraine. This 
symptom will be described under the individual psychoses. 
Headaches that are constant call for a careful Wassermann test 
of the blood and an examination of the urine and the fundus of 
the eye. 
Formications.-Formications, tinglings and numbness occur 
in organic and functional psychoses. Great care should be 
exercised in searching out their origin. 66 
MANUAL OF PSYCHIATRY 
Dizziness.-This condition is a frequent symptom in organic 
disease of the nervous system (tabes dorsalis, paresis, syphilitic 
psychoses, epilepsy). It is also found in hysteria, neurasthenia, 
psychasthenia and the anxiety neuroses. 
Disturbance of Sensibility.-These conditions are found in 
functional and organic disease of the central nervous system. 
Careful diagnostic methods will distinguish between organic and 
functional disturbances. CHAPTER V 
TRAUMATIC PSYCHOSES 
Definition.-The term traumatic psychoses has been applied 
to groups of psychotic, neurotic and physical symptoms of a 
more or less definite clinical character, the origin of which may 
be traced to some trauma, particularly of the head or spine. 
The symptoms are so well defined that these disorders may be 
regarded as definite clinical entities, though it is true that 
hysteria, neurasthenia, dementia praecox, manic depressive psy- 
chosis and paresis may apparently be the sequelae of injuries 
that have acted merely as precipitating factors. These diseases 
are to be eliminated by a process of exclusion. Certain psychotic 
states follow operations, particularly those upon the eye and 
about the face or genitals. These are to be classified with the 
traumatic psychoses group. 
There are four main types of psychotic disturbance associated 
with trauma. They are as follows: 
1. Post Traumatic Delirium. 
2. Traumatic Psychosis. 
3. Post Traumatic Constitution. 
4. Post Traumatic Mental Enfeeblement. 
Etiology.-These psychoses occur more frequently in males 
than in females, owing to the fact that men, by reason of their 
hazardous occupations, are more often injured. Persons of 
unstable nervous organism seem to be more susceptible to the 
development of these disorders, because of their undue reaction 
to trauma. 
Pathology.-The following pathological conditions have been 
found at autopsy: oedema of the brain and meninges; minute 
67 68 
MANUAL OF PSYCHIATRY 
hemorrhages in the cortex at the site of the injury immediately 
after the injury, and remote from the time of injury, scars con- 
taining blood pigment; cystic cavities in the brain substance; 
areas of softening; patches of gliosis, and degenerative changes 
of the nervous elements. 
Symptomatology.-1. Post Traumatic Delirium.-0 f t e n 
there develops, after an injury or operation, a more or less 
protracted delirium which owes its origin to the inflammatory 
reaction involving the membranes and the brain substance- 
a localized meningoencephalitis. Frequently this delirium is 
characterized by extensive confabulations. 
2. Traumatic Psychosis.-Immediately following an injury to 
the head or spine, there may develop a state of unconsciousness 
of indefinite duration. When consciousness is regained the 
patient usually fails to remember anything of the accident or 
happenings of a short time before the accident. Soon after the 
trauma the patient is apparently restored to a normal condition, 
and for weeks, months, or even years, he may display no signs 
of mental failure. There may, however, be focal lesions attended 
by paralysis of some group of muscles or a limb. 
When the true traumatic psychosis does develop the first 
symptom of mental disorder noted is an insidious change in the 
patient's disposition. He becomes irritable and morose, has 
periods of despondency or depression, worries about his health, 
financial matters and kindred affairs. His moral sense becomes 
weakened, and to allay his unpleasant and distraught feelings 
he often resorts to the excessive use of alcoholic beverages, to 
which he shows a marked pathological reaction. The intellectual 
powers generally fail; memory becomes impaired; reason and 
judgment share in the deteriorative process. A degree of emo- 
tional indifference is often noted, the patient taking little interest 
in his environment or his family. It becomes impossible for him 
to carry on his former occupation. These symptoms may con- TRAUMATIC PSYCHOSES 
69 
tinue to increase until there is developed a condition of apathetic 
dementia. 
Crime frequently occurs as a part of the symptom complex, 
and the traumatic psychotic state is often expressed by the 
perpetration of crimes and misdemeanors. 
The physical symptoms which gradually but progressively 
develop are quite pronounced. The patient complains of in- 
somnia, vertigo and tinnitus aurium. He is easily fatigued. 
Great muscular weakness is present. Tremors of the tongue 
and hands are noted. The reflexes are increased and the pupils 
respond slowly to the routine tests for light and accommodation. 
Friedman's Complex.-Friedman has observed that after 
trauma a certain group of symptoms develop which he attributes 
to vasomotor disturbance. This group of symptoms is comprised 
of fullness in the head, headache, vertigo, irritability, insomnia, 
excessive reaction to mental or physical labor, progressive change 
in the character, intolerance of alcoholic liquors and a marked 
memory defect (retrograde amnesia). Occasionally the head- 
ache is expressed by a sensation of fullness, or as though a tight 
band encircled the head. The sensation of constriction or full- 
ness is increased when the patient stoops over. The outbreaks 
of temper resemble those of epilepsy. 
3. Post Traumatic Constitution.-Individuals who have suf- 
fered from trauma to the head, spine, or other portions of the 
body exhibit a peculiar tendency to violent outbreaks of temper 
and mental instability (the explosive diathesis of Kaplan). 
Often there are manifested hysteroid, epileptoid and paranoid 
states which are attended by vasomotor disturbance, fatigability 
and persistent headaches. 
4. Post Traumatic Mental Enfeeblement.-Often there are no 
very definite psychotic symptoms, but there develops a marked 
state of mental enfeeblement in which there is a gradual deterio- 
ration of the mental powers. The patient becomes forgetful, 70 
MANUAL OF PSYCHIATRY 
perception is dulled and ideation is limited. The affairs of the 
external world concern him less and less as time goes on, and 
with this general let-down there is usually marked impairment 
of reason and judgment and a reduction in the patient's powers 
to make adequate adjustments to his environment. 
Differential Diagnosis.-Paresis.-This disease is distin- 
guished by the history and evidence of syphilis, the neurological 
findings, and, in a majority of cases, a positive reaction to the 
Wassermann test of the blood serum and spinal fluid. The 
grandiose ideas, states of euphoria and periods of emotional 
excitement which characterize paresis are absent in traumatic 
insanity. 
Dementia Proecox.-Usually occurs early in life. Is marked 
by progressive mental failure, marked emotional defect, manner- 
isms, negativistic states, transient, unsystematized delusions and 
hallucinations of an absurd character. 
Manic Depressive Insanity.-This disorder is marked by 
periods of depression and elation which may alternate. The 
tendency to deterioration is relatively slight. Recovery from the 
individual attacks is the rule. 
Hysteria.-Hysterical individuals develop psychotic states 
after blows on the head, but the symptoms of hysteria are 
present. Some or all of the following symptoms are usually 
found: the hysterical clavus, globus hystericus, heightened sus- 
ceptibility to external stimulation, alternate periods of depres- 
sion and elation without due cause, concentric constriction of 
the visual fields, disturbances of sensation, convulsive attacks, 
and the other evidences of this psychosis. Mankopf's symptom 
is sometimes observed in hysteria. If pressure is exerted at the 
site of the injury there will be no quickening of the pulse. If 
there has been real injury the pulse rate will be quickened. This 
is not a reliable test. 
It must be borne in mind that trauma sometimes serves as the TRAUMATIC PSYCHOSES 
71 
exciting factor for the development of the above-mentioned 
diseases. 
Psychological Analysis of the Traumatic Psychoses.- 
Perception may be slightly or extensively impaired. Ideation 
is defective and less rapid than formerly. The emotions are 
unstable and mercurial. Will power is weakened and defective. 
The power of inhibition is markedly impaired, as is the capacity 
for decisive action. Mental life is reduced to a lower level. 
Prognosis.-This disorder usually progresses for some time 
and is then arrested at a stage of more or less permanent mental 
weakness. Chances of recovery are unfavorable. Death usually 
occurs by some intercurrent disease. 
Treatment.-Operative measures as a rule afford but little 
relief in the traumatic psychoses. However, operative procedure 
is of some service in a few cases providing it is undertaken early 
in the course of the disorder if there are focal symptoms present. 
At times the patient needs rest and quiet and change of scenery. 
Mild hypnotics may be employed to overcome insomnia. Hydro- 
therapy may be employed in the form of daily hot baths or 
showers, followed by cold spray and brisk rubbing. Psycho- 
therapy is of great value and is employed with the view in mind 
to re-educate the patient, to allay his fears, and to direct his 
more or less blunted mental powers and his reduced productive 
ability into channels of useful endeavor. Brooding about liti- 
gation is decidedly harmful to the patient and should be 
discouraged. 
Occupational therapy should always be tried. The patient's 
mind and hands should be trained in work that is not likely to 
bring him into conflict with his environment. Horticulture, 
agriculture or other manual work may be attempted, as the life 
history of the patient indicates. 
If the patient is a source of danger to himself or to others, he 
should receive institutional treatment. CHAPTER VI 
SENILE PSYCHOSES 
Definition.-The senile psychoses are a group of well-defined 
chronic, progressive mental disorders which develop in aged 
persons when the normal physiological processes of physical and 
mental decay have been exceeded. The chief mental character- 
istics are impairment of memory, especially for recent events, 
disorders of orientation, defect of attention, irritability and 
instability of the emotions, states of depression, paranoid trends 
and disorders of conduct. There are several types of the senile 
psychoses. These more or less overlap, yet the clinical symptoms 
warrant the following classification: 
1. Simple Deterioration. 
2. Presbyophrenic Type. 
3. Delirious and Confused Type. 
4. Depressed and Agitated Type. 
5. Paranoid Type. 
6. Presenile Type (Alzheimer's Disease). 
Etiology.-Age is not altogether determined by the number 
of years that a person has lived. Some persons are physiologi- 
cally younger at the age of seventy than are others at fifty. 
This difference depends upon the degree of arteriosclerosis pres- 
ent in the cerebrovascular system. Senile psychosis makes its 
appearance usually between the ages of sixty and seventy-five. 
Heredity exerts a strong influence in the production of this 
disorder. About 50 per cent of all patients have a history of 
neuropathic taint. It has been noted that there is a tendency 
among some families toward longevity. In others the span of 
72 SENILE PSYCHOSES 
73 
life is shorter because the senile changes occur earlier in the 
circulatory system. Hardship, exposure, alcoholism and syphilis 
are important factors in the development of arteriosclerosis. 
Febrile diseases and emotional and physical shocks are often 
precipitating factors for the production of these psychoses. 
Pathology.-The following pathological conditions have been 
demonstrated at autopsy: 
Gross Pathology 
1. Decrease of brain weight from 
200 to 500 grammes. 
2. Atrophy of the brain. 
3. Shrinking of the convolutions. 
4. Widening of the sulci. 
5. Adhesions of the dura mater to 
the skull. 
6. Increased Pacchionian granula- 
tions. 
7. Thickening of the dura mater 
and the pia mater. 
8. Cystic degeneration of choroid 
plexus. 
9. Granulation of the ependyma. 
10. Dilatation of ventricles. 
11. Increase of fluid in subarach- 
noid space. 
12. Sclerosis of basal blood vessels. 
13. Thrombosis. 
14. Areas of softening of the cortex. 
15. Increase of connective tissue in 
the kidneys and other organs. 
16. Myocarditis. 
Microscopic Pathologij 
1. Degenerative changes of nerve 
cells; vacuolization and atrophy 
of nucleus of the neuroglia cells. 
2. Gland-like enlargements of the 
axis cylinders. 
3. Formation of yellow pigment 
about axis cylinders. 
4. Increase of neuroglia. 
5. Disappearance of tangential 
fibers. 
6. Miliary necroses. 
7. Calcareous placques in pia. 
8. Atrophy of the nerve cells in 
spinal cord. 
9. Atrophy of the fiber tracts of 
spinal cord. 
Symptomatology.-The symptoms of these diseases are 
usually introduced by a prodromal period lasting several months 
and characterized by expressions of irritability and insomnia, 
and frequent attacks of dizziness. The patient becomes very 
seclusive; he shuns the society of his former friends and 
acquaintances. He complains of malaise, muscular weakness 
and anorexia. 
The patient's mental power gradually decreases and the MANUAL OF PSYCHIATRY 
74 
memory "becomes defective, especially for recent events, although 
the scenes and memories of early childhood are usually well 
retained. The patient lives entirely in the past, failing to realize 
the present. The names and the number of his children are 
forgotten, and the events of early morning cannot be remembered 
through the day. In order to fill the gaps in memory we find 
a senile dement resorting to fabrications. If asked the date his 
usual reply will be, "I don't know; I have not looked at the 
calendar." In many cases it is noted that the patient is unable 
to find his way to the dining table or to his bed, and out of doors 
he wanders aimlessly about the streets, unable to locate his 
home. 
Added to this condition of senile dementia we find in some cases 
delusions of persecution. The most common delusions are those 
which relate to property. The senile entertain beliefs that they 
will be robbed; that secret enemies are plotting their ruin; that 
they will be murdered; and many other paranoid beliefs of a 
similar nature. Acting under the influence of such false ideas 
these patients spend their time in barring the windows and doors 
of their homes, and in devising all sorts of schemes to prevent 
bodily and financial misfortune from overtaking them. They 
wander about their homes at night, fully armed, inspecting the 
premises for fear they have overlooked the barricading of some 
entrance which might afford thieves an opportunity to enter. 
As a result of these nocturnal excursions they often suffer severe 
bodily injuries by falling down stairs or over furniture, or by 
setting their clothing on fire while carrying about lanterns, 
matches or candles. 
There is marked change in the emotions. Patients lack the 
usual sympathy exhibited by normal persons. The death of a 
relative fails to impress them; they are indifferent to the sorrows 
and calamities of others; home and friends no longer interest 
them. Exhibitions of penuriousness are common; patients be- SENILE PSYCHOSES 
75 
come miserly. They are obstinate, self-willed, stubborn, very 
easily irritated, dogmatic, and roused to outbreaks of temper 
on the slightest provocation. The moral feelings share in the 
process of degeneration. Often senile dements are obscene in 
their language, make sexual assaults on little children, make 
indecent exposures, and are easily led by designing females to 
enter into marriage contracts. All manner of disorders of conduct 
are to be expected. 
Physical Symptoms.-The signs of physical decay are present. 
The body is generally emaciated; the skin is dry and harsh. 
The hair is gray or white; the superficial blood vessels are 
sclerosed. The temporal arteries are tortuous and easily seen, 
and opacities of the vitreous body and cataracts of the crystal- 
line lens are common. The eyes generally show the arcus senilis. 
Areas of paresthesia and anesthesia are found in different parts 
of the body, and epileptiform convulsions are not infrequent. 
The convulsions may be of a major or minor character, and 
sometimes are of the Jacksonian variety. Focal lesions are 
often noted and are usually attended by motor aphasia, verbal 
deafness, paraphasia and dysgraphia. Transient hemiplegias are 
known to occur, and permanent paralysis may develop, due to 
softening of the cerebral cortex. The focal symptoms occur most 
frequently in those cases marked by periods of confusion. 
These are the symptoms in general. The various types which 
have been enumerated show special groupings of symptoms, 
which follow. 
Simple Deterioration.-This is a common form. The memory 
is much impaired. The mental capacities are reduced. The 
patient becomes egocentric, is very irritable and fault-finding, 
and displays marked psychomotor activity. The symptoms are 
usually worse at night. Orientation is not much disturbed in 
this form. I 
Presbyophrenic Type.-This type of senile dementia bears a 76 
MANUAL OF PSYCHIATRY 
close resemblance to Karsakow's psychosis. The patient is 
markedly disoriented in the spheres of time and place, and he 
fills in the gaps of memory by elaborate falsifications. Often 
a bedridden patient will explain to his physician or to those 
about him that he was out the night before to a dinner party, 
or that he has just returned from a long hunting trip. The 
impairment of memory is pronounced and the patient continually 
makes contradictory statements and is given to exaggerations. 
Delirious and Confused Types.-In these types there are 
marked confusional states, associated with fleeting delusions and 
hallucinations. The patients are active, restless, noisy, and 
display marked periods of irritability. It is quite difficult to 
restrain them, and often the psychomotor activity is so great 
that they soon exhaust themselves, and death is not an infre- 
quent result. 
Depressed and Agitated Types.-The patients suffering from 
this form are usually very greatly depressed, but keep in a 
constant state of movement, such as weaving back and forth 
in their chairs, wringing their hands or pacing the floor. 
Paranoid Type.-In this form, as the name indicates, the 
delusions are decidedly paranoid. The false beliefs are usually 
of a grandiose or persecutory nature. Delusions of marital 
infidelity are common. 
Presenile Type (Alzheimer's Disease).-Alzheimer described, 
in 1906, the symptom complex which bears his name. He found 
that the symptoms usually manifested themselves between the 
ages of forty and sixty. The chief symptom is a rapidly pro- 
gressing dementia which is punctuated by periods of excitement 
and depression. The patient is usually completely disoriented 
in some sphere, or there may be incomplete disorientation in 
all spheres. Focal symptoms are quite common. The patient 
has particular difficulty in speaking distinctly. Often there is 
aphasia or paraphasia and asymbolia. The general body muscles SENILE PSYCHOSES 
77 
become stiff, the gait becomes slightly spastic, and convulsions 
are occasionally developed. Apraxia has been noted in this 
condition. Some authors are inclined to regard this disease as 
a distinct entity, but it is the consensus of opinion that this 
symptom complex is but an expression of an oncoming senile 
dementia or arteriosclerosis. 
Diagnosis.-The diagnosis of the senile psychoses is not 
usually difficult. The age and general appearance of the patient 
indicate the nature of disorder. 
Paranoia begins earlier in life and the signs of mental decay 
are not usually present, though the paranoiac may suffer from 
senile dementia. The usual course of paranoia is not found in 
senile dementia. 
A condition of simple dementia is frequently an attendant of 
the senium and is not to be confused with the senile psychoses. 
General paresis occurs most commonly about the fourth decade 
of life. The evidences of syphilis are found in paresis. The 
Wassermann test is practically always positive with the blood 
and spinal fluid. There is an increase in the cell count of the 
spinal fluid; also an increase in the albumen and globulin con- 
tent. The neurological findings are characteristic, but occasion- 
ally they bear a close resemblance to the focal disturbances of 
senile dementia. 
Manic depressive psychosis usually occurs earlier in life. It 
is characterized by recurring attacks of depression and mania. 
Manic depressive psychoses are not attended by states of 
dementia. 
In arteriosclerotic dementia the differentiation is more diffi- 
cult. The focal lesions are more common in arteriosclerotic 
dementia, irritability is more frequent, and the degree of 
dementia is not so marked. 
Psychological Analysis.-General impairment of perception, 
defects of consciousness, disorders of memory, reduction of 78 
MANUAL OF PSYCHIATRY 
capacities for reason and judgment, affective disturbances, 
dilapidation of ethical perceptions, disorders of conduct, and 
failure of ability to make necessary adjustments to environment. 
Prognosis.-The senile psychoses usually last from one to 
four years, death finally occurring from exhaustion or from some 
intercurrent disease such as senile pneumonia, chronic colitis, 
decubitus or cystitis. 
Treatment.-The treatment in these cases is custodial, die- 
tetic and hygienic. Patients should be carefully watched so that 
they may not injure themselves or others; great precautions 
should be taken to see that they do not wander about their 
homes at night and that they do not set fire to property. They 
should receive plenty of wholesome, easily digestible, nourishing 
food; the clothing should be warm, to prevent chilling of the 
body. For the treatment of insomnia, which is usually a most 
intractable symptom, warm milk or other light nourishment may 
be given at bedtime, together with hypnotic remedies, as paralde- 
hyde, chloralamide, veronal and other sedative drugs. Brandy 
and whiskey in small doses may be cautiously given with good 
effect. Prolonged warm baths may be employed with caution 
in cases of extreme restlessness and violence. Patients who are 
markedly hard to control should be committed to state hospitals 
for the insane or to similar institutions. CHAPTER VII 
PSYCHOSES WITH CEREBRAL 
ARTERIOSCLEROSIS 
Definition.-This is a chronic, progressive group of psychoses 
which occur usually about the sixtieth year and which are 
marked by pronounced impairment, great emotional instability, 
episodes of confusion and focal lesions. There are four main 
forms of these psychoses, as follows: 
1. Arteriosclerotic Brain Atrophy. 
2. Subcortical Encephalitis. 
2. Perivascular Gliosis. 
4. Senile Cortical Devastation. 
Etiology.-These diseased conditions, as the names imply, are 
dependent upon degenerative changes in the cerebral arterial 
system. Alcohol, syphilis, and various toxemias and endogenous 
poisons that are prominent in the production of arteriosclerosis 
are important in the production of these psychoses. Hereditary 
predisposition, excesses, exposure and overwork are also impor- 
tant etiological factors. Males are most frequently affected. 
Pathology 
Gross Pathology 
1. Thickening of the cerebral ves- 
sels. 
2. Thickening of the dura mater 
and pia mater. 
3. Atrophy of the brain. 
4. Areas of softening. 
5. Loss in brain weight. 
6. Hemorrhagic softening in brain 
substance. 
7. Dilatation of the ventricles. 
8. Cardiac hypertrophy or dilata- 
tion. 
9. Interstitial nephritis. 
Microscopic Pathology 
1. Increase of neuroglia. 
2. Thickening of the capillary ves- 
sel walls. 
3. Pigmentation of the cortical cells. 
4. Increase of connective tissue in 
lymph spaces. 
5. Increase in granular cells. 
6. Vacuolization of white matter. 
79 80 
MANUAL OF PSYCHIATRY 
Symptomatology.-Arteriosclerotic Brain Atrophy.-The 
main symptoms of this type are dizziness, headache, mental 
fatigue and failure of memory. This form usually ends in a 
state of profound dementia. Focal symptoms are common. 
Subcortical Encephalitis.-In this type, which is due to 
changes in the long medullary arteries, we have attacks of con- 
fusion, temporary aphasias and paralyses and occasional epilep- 
toid convulsions. 
Perivascular Gliosis.-In this type the symptoms are essen- 
tially the same as in other forms of arteriosclerotic insanity. 
The pathology shows an increase of the neuroglia about the 
diseased blood vessels and a destruction of the nerve cells and 
their processes. 
Senile Cortical Devastation.-As the name implies, there is 
gross destruction of the cortex in or about the cerebral vessels. 
Often the whole lobe or portions of the lobe are involved. Many 
focal lesions are present, which, according to their location, 
produce blindness or deafness, or paralyses in various portions 
of the body. 
General Symptomatology.-There is a wide variation of the 
symptoms. The disease finally leads to dementia. Before this 
terminal stage there are marked periods of confusion, dizziness 
and forgetfulness, and states of irritability which alternate with 
periods of good humor and lucidity during which the patient is 
usually able to care for himself. Emotional instability is a 
marked symptom of this disease, and the changes in the emotions 
are very sudden and excessive. Tears and laughter may often 
be produced by suggestion within the space of a minute. Some- 
times the disease progresses very slowly, and this is true of those 
cases where the individual leads a quiet, regular life and receives 
early treatment. Apoplectic attacks are common and with each 
attack the mental powers decrease, until in the end the patient 
must be cared for as an infant. Conditions of aphasia, agraphia, PSYCHOSES WITH CEREBRAL ARTERIOSCLEROSIS 
81 
apraxia and mind blindness are very frequent, and these symp- 
toms make the mental deterioration appear more profound than 
it really is. Occasionally very rapidly developing forms are 
encountered. These are ushered in with apoplectiform seizures, 
violent headaches, periods of anxiety and marked delusions of 
persecution. In this form the patients are often suicidal and 
homicidal. If the progress of the disease is not arrested, death 
soon occurs. As a rule the course of the disease is about four 
years, although death may occur within six months. 
Diagnosis.-The diagnosis is many times quite difficult 
because of the resemblance to other diseases of the senium. 
Paresis.-It is difficult to distinguish this disease from paresis 
during the early stages. In paresis we expect the usual syphilitic 
reactions of the blood and spinal fluid and an increased cell 
count. In paresis the lesions of the cortex are diffused, while 
in arteriosclerotic psychosis they are scattered. 
Syphilitic Psychoses.-It is quite difficult in the early stages to 
differentiate arteriosclerotic dementia from the syphilitic psy- 
choses. The syphilitic psychoses as a rule present a positive 
Wassermann of the blood and spinal fluid and an increased cell 
count. The mental symptoms develop at a slower rate, and the 
mental disturbances are less profound in the syphilitic psychoses. 
The pupillary anomalies are more constant in brain syphilis than 
in arteriosclerotic dementia. 
Senile Psychosis.-The focal changes are not so pronounced in 
the senile psychoses. The patient is usually older and the symp- 
toms of dementia are more profound. 
Psychological Analysis.-Varying degrees of impairment of 
perception. Disorders of consciousness, emotional disturbances, 
reduction of the powers of reason and judgment and deviations 
in conduct. 
Prognosis.-The prognosis is unfavorable. 82 
MANUAL OF PSYCHIATRY 
Treatment.-The treatment is chiefly dietetic, hygienic and 
symptomatic. Foods should be of a simple sort. The use of 
alcohol and tobacco should be interdicted. The emunctory 
organs should receive careful attention. Hypnotics and seda- 
tives may be employed with hydrotherapy to control the 
insomnia and excitement. In the terminal stages of this disease 
it becomes necessary to commit the patients to hospitals for 
the insane. 
The medication is largely symptomatic. Potassium iodide 
may be tried, but its value is rather questionable. Foods which 
contain cholesterin should be reduced to a minimum. Labora- 
tory experiments would indicate that the use of potassium iodide 
is contraindicated on the ground that arterial sclerosis is due to 
the deposit of cholesterin within the walls of the arterial vessels, 
and that the iodides form insoluble compounds with cholesterin. 
Further laboratory experiments have shown that the hypophos- 
phites are capable of reducing arterial sclerosis in animals, and 
limited experiments with human beings have demonstrated that 
a cholesterin free diet and the use of hypophosphites is of value 
in reducing the blood pressure in arteriosclerotic patients. How- 
ever, we are to bear in mind the results of long clinical expe- 
rience. It has been held by various authorities that potassium 
iodide is very serviceable in arteriosclerotic conditions, and the 
conclusions of these clinicians are not to be hastily discredited. 
It may be, however, that the cases in which potassium iodide 
exerted a beneficial effect were those in which the arteriosclerosis 
was of luetic origin. CHAPTER VIII 
GENERAL PARESIS 
Definition.-General paresis is a chronic psychosis usually 
appearing in middle life, characterized by progressive mental 
deterioration leading to complete dementia and terminating 
fatally. It is attended by irritative and paralytic symptoms 
due to gross changes in the cerebrospinal nervous system. Death 
usually occurs within thirty-six months. 
Juvenile paresis is now known to be of not infrequent occur- 
rence. It makes its appearance usually before the age of twenty 
years. The majority of the cases develop between the ages of 
ten and twenty years. It is attended by essentially the same 
progressive psychotic symptoms and nervous phenomena found 
in adult paretics. It always ends in death, after running a 
course of from two to four years. 
Etiology.-This disease is due to syphilis. It is more common 
in the male than in the female. The greatest number of cases 
develop between the ages of thirty and fifty years, but it may 
occur in any decade of life. It appears usually in from ten to. 
twenty years after infection with syphilis. Syphilitics who use 
alcohol seem to be far more susceptible to the development of 
this disease. It is often found to have been precipitated by 
blows or falls on the head or spinal column, and other injuries 
to the body. Conservative American authorities have estimated 
that from 15 to 25 per cent of the admissions to hospitals for 
the insane are due to paresis. European institutions show a still 
higher rate of admission of paretics. 
83 84 
MANUAL OF PSYCHIATRY 
Pathology 
Gross Pathology 
1. Exostoses of the cranial bones. 
2. Hyperostoses. 
3. Atrophy of the cortex. 
4. Broadening of the fissures. 
5. Atrophy of the frontal lobes of 
the brain. 
6. Decrease in the weight of the 
brain. 
7. Inflammation of and gross 
changes in the meninges. 
8. The brain and meninges have a 
moth-eaten appearance. 
9. Thickening of the meninges. 
10. Increase in the Pacchionian 
granulations. 
11. Dilatation of the ventricles. 
12. Granulation of the ependyma. 
13. The presence of opalescent, 
milky fluid in the meninges. 
14. Softening of the brain sub- 
stance. 
1$. The presence of spirochaete 
pallida in the brain substance. 
16. Fragility of the bones. 
17. Degenerative changes of heart 
muscle and aorta. 
18. Degenerative changes in kid- 
neys and liver. 
Microscopic Pathology 
1. Proliferation of capillaries. 
2. Cell sclerosis in cortex. 
3. Increase in the neuroglia. 
4. Destruction of the myelin sheath. 
5. Atrophy of the nerve fibers. 
6. Presence of plasma cells in the 
dilated lymph spaces. 
7. Presence of spider cells. 
8. Presence of yellow pigment. 
The spinal cord shares in the 
same process as does the brain 
substance and its meninges, but 
to a lesser degree. 
Blood.-The blood in practically all cases shows a positive 
Wassermann reaction. There are, however, occasional excep- 
tions. The ingestion by the patient of alcohol a few hours before 
the taking of the blood for a Wassermann test may modify the 
results and a negative may be obtained. Vigorous anti-syphilitic 
treatment may temporarily produce a negative Wassermann of 
the blood. 
Cerebrospinal Fluid.-As a rule the cerebrospinal fluid in 
paresis shows a positive Wassermann reaction, though there are 
some exceptions. There is usually an increase in the number of GENERAL PARESIS 
85 
lymphocytes. A cell count above five should rouse suspicions 
of the presence of some form of meningitis. The chemical exami- 
nation shows usually an increase in the globulin content. From 
a laboratory point of view, before making a diagnosis of paresis 
there should be definite positive findings: 
1. The Wassermann of the blood should be positive. 
2. The Wassermann of the cerebrospinal fluid should be 
positive. 
3. There should be an increase in the cell count of the cerebro- 
spinal fluid. 
4. There should be an increase of the globulin content of the 
spinal fluid. 
These tests are to be interpreted in conjunction with the clin- 
ical symptoms. The diagnosis of general paresis and other types 
of nerve syphilis is not to be made on the laboratory findings 
alone. Errors in technic are always possible. It has been estab- 
lished by Solomon and by Klauder, and it has been the experience 
of the author, that there are conditions of nerve syphilis in which 
the cerebrospinal fluid may be negative at the time the patient 
comes under the observation of the clinician. This statement is 
true of general paresis, tabes dorsalis, syphilitic epilepsy, Erb's 
syphilitic spastic paraplegia, syphilitic nerve palsies, cerebral 
gumma and the syphilitic psychoses. 
Symptomatology.-General Symptomatology.-General pa- 
resis occurs in four relatively distinct forms, differentiated 
according to the character of the predominating symptoms. 
These differences in the expression of paresis seem to depend 
upon the personality of the patient. The forms are as follows: 
Demented Form 
Expansive Form 
Agitated Form 
Depressed Form. 86 
MANUAL OF PSYCHIATRY 
The disease is usually slow in its onset; there is a gradual 
change in the patient's disposition. He fails to react in a normal 
manner to his environment. The mentality seems to be en- 
veloped in a stupor. There is generally a reversal of the indi- 
vidual's usual traits of character; the formerly moral man 
becomes dissolute; the honest man becomes a prevaricator; the 
ambitious person becomes lazy. The mental processes show 
dilapidation. Voluntary attention fails. The memory becomes 
poor. Judgment is impaired. The patient complains of extreme 
fatigue on slight exertion. His ability to comprehend the situa- 
tions in which he lives grows progressively feeble. He finds it 
difficult to take on new ideas. He indulges in fabrications to 
account for changes of which he has no memory. At first 
patients usually have some insight into their condition; they 
recognize the fact that they are irritated by trifles and that they 
are lacking in their usual capacity to accomplish work, but this 
state does not ordinarily last very long. The deteriorating 
process is more or less rapid. Paretics commit grave offenses 
against the law, make foolish investments, write checks for 
immense amounts of money, commit overt sexual acts, and other- 
wise conduct themselves abnormally. The picture presented is 
that which attends gradual failure of mental power. 
' Neurological Symptoms.-In the beginning stage the patient 
suffers from headache and dizziness and has feelings of pressure 
within the head. The senses of smell and taste are often per- 
verted; it is difficult for the patient to distinguish between sub- 
stances that are sweet, sour, salty or bitter. There are disturb- 
ances in the sensations. The patient often has a feeling of 
burning in various parts of the body; later the skin becomes 
insensitive to pin pricks and there may be scattered spots of 
anesthesia throughout the body. The motor symptoms are quite 
pronounced. Paralytic and convulsive attacks occur in about 50 
per cent of the cases. Often there are Jacksonian convulsions of GENERAL PARESIS 
87 
some group of muscles or some member of the body. Apoplecti- 
form seizures are not infrequent. These are usually accom- 
panied by loss of consciousness, high temperature and stertorous 
breathing. 
The muscles of the face become flaccid; the lines of expression 
are erased; the face has a washed-out appearance. There is a 
fine tremor about the naso-labial fold. The voice changes; it 
becomes monotonous. The speech is defective. The patient 
stumbles over the usual test words and phrases. As the disease 
progresses the patient chews his tongue and grits his teeth. There 
are often transient paralyses of the eye muscles. The pupils 
become unequal in about 50 per cent of all cases. Argyll- 
Robertson pupils are very common. The patient loses his ability 
to perform delicate movements. The handwriting becomes an 
illegible scrawl. His gait becomes shuffling and slouchy. If he 
turns about quickly he stumbles or loses his balance. He finds 
difficulty in buttoning his clothes properly. The tendon reflexes 
are at first usually exaggerated, and tapping the tendons is often 
sufficient to set all the muscles in the body jerking. There is 
inequality of the patellar reflexes. Later these may be lost 
altogether. The vasomotor disturbances are frequent. There 
is flushing of the face with rushes of blood to the head. There 
is cyanosis of the extremities and dermatographia. The tendency 
to bed sores is quite pronounced. At first the sleep is much 
disturbed. Later on the patient becomes very sluggish and finds 
great difficulty in keeping awake during the day. The nutrition 
at first suffers a deteriorating process, but as the disease 
progresses the patient usually develops a voracious appetite, 
swallows his food without chewing it, and seems to lose the sense 
of taste. 
The symptoms described comprise the general symptom com- 
plex. According to the grouping and the predominant charac- 88 
MANUAL OF PSYCHIATRY 
teristics of the symptoms and their rate of development, the four 
forms that have been mentioned are differentiated. 
Demented Form.-In this type there is generally an absence 
of delusions and hallucinations. The disease progresses rapidly 
to a state of complete dementia, usually without any remissions. 
There are occasional periods of restlessness and excitement, often 
punctuated by states of depression. This form comes on insidi- 
ously. The symptoms at first are those of neurasthenia. The 
patient has feelings of incapacity, has headaches, is drowsy, 
forgetful, often confused. He shows marked errors in judgment, 
loses his ethical sensibilities, finds it difficult to pursue his daily 
work, which he slights or neglects altogether. As the disease 
progresses consciousness becomes clouded and confused. There 
may frequently appear transitory hallucinations and delusions 
which may be largely affected by suggestion. They play no 
prominent part, however, in this type of the disease. There is 
a lack of capacity for earning a livelihood, and due to their 
marked inability to adjust themselves to the environment in 
which they live, the patients are absolutely helpless and must 
be cared for constantly by friends or relatives or be committed 
to institutions. This type of the disease forms about 40 per cent 
of the cases of paresis. Of these cases perhaps one-half live 
more than twenty-four months. Approximately one-fifth of 
them die within the first year. 
Expansive Form.-In this form, delusions of a grandiose 
nature are present. There is a tendency to remission and the 
disease runs a more prolonged course. The patient shows the 
usual signs of dementia, following a short period of depression 
in which delusions of persecution and anxiety predominate. The 
patient develops ideas of an expansive type. There is a marked 
state of euphoria. He becomes quite active. He may explain 
that he has the strongest body in the world; that he has the 
greatest intellect; that he is the most wonderful musician; that GENERAL PARESIS 
89 
he is a great legal light; that he possesses millions of dollars; 
that he owns the institution in which he is a patient; that he 
owns half of the universe; that he has houses full of diamonds. 
These delusions increase from day to day, and the patient fails 
to see their utter absurdity. He becomes rather irritable and 
combative at times when he is not allowed to behave in accord- 
ance with his delusions. No idea is too extravagant for these 
patients to have. They are disoriented, usually, as to time and 
place. They are too busy with their grandiose ideas to take 
any notice of persons or conditions 'within their environment. 
There is increased psychomotor activity. Patients write great 
piles of letters, send numerous telegrams, are very talkative, 
pace wildly up and down their wards, often shout and curse at 
other inmates, sometimes mutilate their bodies. But these 
periods of excitement soon pass off, leaving the patient calm and 
peaceful. Crimes are common with this type. Patients are 
given to theft; they appropriate anything within their reach 
without any apparent knowledge of the quality of their acts. 
They are inclined to make sexual assaults. This type of the 
disease is found in from 15 to 25 per cent of all cases. About 
two-thirds of these cases live more than two years. Remissions 
occur in perhaps one-third of all cases of this type. 
Agitated Form.-This form has a relatively sudden onset. 
There is great psychomotor activity, often attended by delusions 
of grandeur. Consciousness is usually clouded. Patients who 
were formerly quiet and slow in movement suddenly become 
extremely energetic; often think that they have had a new 
birth; that they have the strength of a thousand men; that they 
are creators of the universe; that they have fabulous wealth. 
In conjunction with these expansive delusions patients complain 
of pains throughout the body; say that ingenious tortures have 
been devised to make them suffer; that they have some weird 
disease; that they are suffering a process of purification. They 90 
MANUAL OF PSYCHIATRY 
are rarely depressed on account of these ideas. They are given 
to singing, shouting and impulsive actions, and indulge in cease- 
less and unproductive activities. They tear the bedclothing, tear 
their clothes, break up furniture, and commit sexual excesses of 
all kinds. Their extreme restlessness interferes with the taking 
of food and there is rapid loss of weight and strength. The 
agitation is so great in some cases that the name of Galloping 
Paresis has been applied. Patients of this type live but a few 
months at most. They are never still a minute. They make 
all manner of extravagant and reckless movements, bruise their 
bodies in their excitement, run into the walls of their rooms, 
refuse food and do not sleep. The wounds and scratches they 
inflict upon themselves often become infected. In addition to 
other symptoms they show evidences of profound autointoxica- 
tion and infection. This form of paresis occurs in from 10 to 
15 per cent of all cases. Remissions appear in about one case 
out of four. Approximately two-thirds of the patients die within 
two years. 
Depressed Form.-Associated with the general symptoms of 
paresis there are in this type periods of marked despondency 
and depression. The delusions that exist are of a depressive 
nature. This type of the disease begins slowly by a gradual 
decrease in the mental powers. The patient complains of per- 
sistent headache and great weariness on slight exertion. He is 
hypochondriacal, constantly worried about himself, fears that 
he is suffering from an incurable disease. He complains that his 
blood is dried up; that he has syphilis and must not be touched 
by anyone; that the members of his body rot off; that his brain 
decays; that his stomach is clogged up; that he exhales poison- 
ous gases and gives off poisonous fumes from his body; that 
parts of his body turn to stone. Often the patient has a self- 
accusatory delusion. He tells his friends that he is the greatest 
sinner in the world; that he has committed a sin against the GENERAL PARESIS 
91 
Holy Ghost; that he must suffer extremely because of his sins; 
that he has neglected his friends and relatives and children. 
Patients believe that they are to be hanged, electrocuted or 
quartered, and are in a constant of terror. They hear persons 
talking about them, saying that they are thieves, robbers and 
murderers. They hear the voice of God threatening them with 
terrible punishment, and have other ideas of a similar nature. 
As a rule consciousness is clouded. Orientation is incomplete. 
They keep apart from others, lie on the floor in a heap, crawl 
under the bed, bury their heads in the bedclothes, disfigure the 
genital organs and otherwise mutilate their bodies. They often 
cry and moan for weeks at a time, and appear to be greatly 
depressed when quiet. As the psychomotor activity subsides the 
patients go into a more or less stuporous state, become perfectly 
quiet, refuse all food and fail to attend to the wants of nature. 
All symptoms take on a depressive, fearful coloring. This type 
of general paresis is found in about 25 per cent of all cases. It 
occurs in the fourth decade usually. Remissions are observed 
in about 10 to 15 per cent of the cases. From 60 to 80 per cent 
of the patients afflicted with this type die within twenty-four 
months. 
Diagnosis.-In well-developed cases of paresis little or no 
difficulty is encountered in making a diagnosis. The change of 
disposition, the gradual failure of mental powers, the existence 
of bizarre delusions, the utter lack of judgment, and the inability 
of the individual to adjust himself to his environment, the neuro- 
logical signs such as disorders of the tendon reflexes, sluggishness, 
irregularity and inequality of the pupils or the presence of the 
Argyll-Robertson pupil, conditions of ataxia and tremor, to- 
gether with a positive Wassermann reaction of the blood serum 
and spinal fluid and an increased cell count of the spinal fluid, 
leave no room for doubt. 
Cerebral Syphilis.-The differentiation between cerebral syph- 92 
MANUAL OF PSYCHIATRY 
ilis and paresis is quite difficult in the early stages of these 
disorders. In fact, a thorough course of antisyphilitic treatment 
is the only test that can be made. In cerebral syphilis the 
headaches are usually worse at night. The lesions in the brain 
are generally focal and the cranial nerves below the third are 
the ones usually affected. The bizarre delusions are absent and 
the mental deterioration is very much less. The Wassermann 
reaction of the spinal fluid is frequently negative. Response to 
treatment is often quite marked in cerebral syphilis. 
Manic Depressive Insanity.-This disorder does not present 
the neurological signs of paresis nor evidences of dementia. 
There is usually a history of repeated attacks. 
Senile Dementia.-This psychosis occurs during the senium 
and the course is prolonged. The delusions are not grandiose 
nor are they so bizarre and absurd as in paresis. The character- 
istic neurological symptoms of paresis are absent and the spinal 
fluid is negative to the Wassermann test. 
Arteriosclerotic Dementia.-In paresis the apoplectic insults 
occur after the disease has been fully established. In arterio- 
sclerotic dementia these attacks often precede the mental dis- 
turbances. In paresis grandiose delusions and states of euphoria 
are common, while in arteriosclerotic dementia quite the reverse 
is true. The arteriosclerotic dement often retains his mental 
powers to a considerable degree and is more able than the paretic 
to conduct himself in accord with social customs. Focal symp- 
toms, chief among which are aphasia, hemianopsis, astereognosis, 
spasms and contractures, are more common in arteriosclerotic 
dementia. 
Neurasthenia.-In this disorder the characteristic neurological 
signs of paresis are absent. The paretic is rarely worried about 
his condition and never does he have a true insight into his 
disorder after it has been fairly well established. The neuras- 
thenic is always worried and greatly concerned about his aches, GENERAL PARESIS 
93 
pains and uncomfortable sensations and is constantly seeking 
medical attention. 
Alcoholism.-Here the diagnosis from the clinical symptoms 
alone is somewhat difficult, especially in those conditions that 
have been labeled alcoholic pseudo-paresis, in which pupillary 
and reflex disturbances are found. These paretic-like symptoms 
disappear on the withdrawal of alcohol. Spinal fluid examina- 
tion will usually clear the diagnosis. 
Psychological Analysis.-Sensation and perception are 
markedly impaired and finally abolished in the later stages of 
the disease. Memory is disordered. Ideation, at first lively, 
though erratic, becomes feeble and is later entirely lost. Reason 
and judgment are hopelessly impaired. Absurd and bizarre 
delusions are common. The emotions are profoundly impaired 
and unstable, leading to disorders of conduct. Finally, if the 
patient does not die of some intercurrent disorder, mental 
activity practically disappears and he lives a merely vegetative 
existence. 
General Course.-The course is arbitrarily divided into three 
periods, but the lines of division are more or less indistinct. 
First is the stage of onset, in which the symptoms are those of 
neurasthenia. As the disease progresses the symptoms take on 
the character of the second stage and become very acute. In 
the third or terminal stage of dementia all mentality is lost. 
The patient is in reality but an animated lump of clay and is 
usually bedridden and filthy. He becomes extremely emaciated, 
and contractures of the body muscles are general. At any time 
during this stage of the disease the patient may have paralytic 
attacks of a transient or permanent character. Occasionally 
patients die in convulsions in the beginning stages of the disease. 
Often periods of remission are observed, which may last for 
several months. Patients then usually have some insight into 
their condition and the experiences of their illness appear to 94 
MANUAL OF PSYCHIATRY 
them as a dream. The periods of remission last usually about 
three or four months and occasionally as long as a year. 
Prognosis.-The prognosis is absolutely unfavorable. In the 
majority of cases death occurs within two years. A few cases 
survive as long as six years. In cases surviving longer than this 
period of time there is grave doubt that a correct diagnosis has 
been made. Occasionally there are periods of remission and 
lucid intervals which last from one month to twelve. 
Treatment.-This psychosis is at all stages best treated in a 
sanitarium, for the patient is a potential danger to himself and 
others. Just as soon as the diagnosis has been properly deter- 
mined, a competent guardian or trustee should be appointed to 
care for the patient's business affairs and for his person. 
As the differentiation between the exudative and parenchyma- 
tous types of nerve syphilis is not always possible by methods 
of neuropsychiatric examination, intense anti-syphilitic treat- 
ment is always to be instituted, provided the condition of the 
patient warrants it. An attitude of therapeutic nihilism is not 
to be entertained. Mercury may be given by inunction, intra- 
venously or intramuscularly. Salvarsan or neosalvarsan may 
be employed both intravenously and intraspinally. Clinicians 
now generally concede that the intravenous method of treatment 
is just as effective as the intraspinal and less dangerous. 
Hydrotherapy is of advantage in controlling the occasional 
excitements of paresis and in preventing the development of bed 
sores. 
Medication, aside from specific treatment, is symptomatic. 
Sedative drugs are to be given to control convulsive attacks and CHAPTER IX 
PSYCHOSES WITH CEREBRAL SYPHILIS 
Definition.-Syphilis may be attended at any period of its 
course by a train of mental symptoms which directly owe their 
origin to the disease itself. According to the predominant patho- 
logical characteristics, four types, more or less definite, have been 
recognized, as follows: 
Meningitic Type 
Endarteritic Type 
Gummatous Type 
Mixed Type. 
Meningitic Type.-Syphilitic psychoses of the meningitic type 
are attended by states of delirium, stupidity and confusion, pre- 
ceded by feelings of fullness in the head, dizziness, headaches, 
vague pains about the body and usually involvement of some 
cranial nerve. 
Endarteritic Type.-In this type there are focal symptoms 
which correspond to the vascular areas involved. This form of 
cerebral lues is the most frequently observed, and it resembles 
cerebral arteriosclerosis very closely in its clinical manifesta- 
tions. 
Gummatous Type.-In this type slow-developing focal lesions 
are found, which give rise to various pressure symptoms such as 
hemiplegia, convulsions, aphasia and hemianopsia, according to 
the location of the gummata. It is often difficult to distinguish 
this form of cerebral lues from non-luetic types of brain tumor 
and from diffuse forms of the meningitic type. 
95 96 
MANUAL OF PSYCHIATRY 
Mixed Type.-Many cases of brain syphilis exhibit symptoms 
of all three of the types just described. 
Etiology.-Men are more frequently affected than women. 
Persons who have neglected treatment entirely, or who have 
received insufficient therapy, or who have indulged regularly in 
alcoholic liquors, seem to be particularly susceptible to the 
development of brain syphilis. Trauma is apparently a potent 
factor in precipitating nerve syphilis. Hardship and exposure 
seem to play a similar role. Some persons, by reason of their 
cortical inferiority, seem to be so constituted as to favor the 
development of cerebral syphilis. 
Pathology.-The following described pathological conditions 
have been found by various pathologists: 
1. Thickening of the skull. 
2. Thickening of the meninges. 
3. Encephalitis. 
4. Gummata, any location. 
5. Periarteritis and endarteritis. 
6. Changes in the basal ganglia. 
7. Luetic endocarditis. 
8. Endarteritis of the smaller blood 
vessels. 
9. Histopathological changes in the 
cortex. 
Symptomatology.-The symptoms of the syphilitic psychoses 
will be described according to the time of their appearance with 
reference to the several stages of syphilis. 
Primary Stage.-It is very rare for mental symptoms to make 
their appearance during the stage of chancre, yet psychotic dis- 
turbances are sometimes noticed. If the patient be a neuropathic 
individual, the knowledge that he has acquired syphilis may 
serve as a powerful psychogenetic factor in the production of a 
very acute depression which is independent of the toxins of 
syphilis itself. As a result marked states of hysteria are noticed, 
the patient loses his appetite, suffers from insomnia, becomes 
dizzy at intervals and shows well-developed signs of asthenia. 
A true anxiety neurosis is developed. The syphilophobia be- 
comes so persistent and painful that the patient visits one physi- 
cian after another, hoping to learn that there has possibly been PSYCHOSES WITH CEREBRAL SYPHILIS 
97 
a mistake in the diagnosis. These unfortunate persons are often 
the victims of quacks. Occasionally they commit suicide. 
Secondary Stage.-Psychopathic states are more common 
during the secondary period. They may appear in the form of 
a delirium in which there is a great increase in the psychomotor 
activity, ranging from simple cerebral excitement to states of 
mania attended by automatic agitation, incoherence and vio- 
lence. After this state of mental alienation there may follow a 
condition of sluggishness and lethargy, a clouding of conscious- 
ness, defective ideation and a perversion of the sentiments. Often 
the patient is irritable, exceedingly morose and sullen. He may 
entertain delusions of persecution. He may be fearful of poi- 
soning or of secret enemies. The delusions are usually attended 
by olfactory, gustatory and aural hallucinations. Often patients 
complain that their food is poisoned or that foul odors and 
poisonous gases are injected into their rooms. Periods of con- 
fusion are noted. In some cases there is headache, insomnia and 
loss of memory. In patients with the psychotic symptoms 
described we generally find that there is a slight elevation of 
temperature. With the subsidence of the acute physical symp- 
toms of the secondary stage the mental phenomena usually 
disappear. Criminal acts of a violent nature are occasionally 
committed by these patients. While the author was Superin- 
tendent of the Indiana Hospital for Insane Criminals four 
persons were committed to that institution for acts that were 
directly the result of these syphilitic psychotic states. Two had 
committed murder, one had attempted assault and battery to 
rape, and the fourth had been convicted of bigamy. Confusion, 
irritability, disorientation and blunting of the moral attributes 
of the mind were the characteristic symptoms. In each case the 
secondary skin eruption had been absent but a short while. 
Tertiary and Quaternary States.-The mental disturbances 
that occur during these periods are usually attended by evi- 98 
MANUAL OF PSYCHIATRY 
dences of organic disease of the central nervous system. Focal 
lesions of the nervous system are likely to be found. The 
symptoms that will be described are in addition to those men- 
tioned in the chapter on paresis. Kraepelin describes a condition 
to which he has applied the term syphilitic neurasthenia, in 
which the usual signs of neurasthenia are exhibited. There is a 
general feeling of malaise, with vague pains about the body, lack 
of power to think clearly and for any length of time, insomnia, 
transient periods of dizziness, thickness of speech, disturbances 
of temperature and frequent attacks of nausea. The symptoms 
resemble somewhat the psychotic disturbances of an acute infec- 
tion. Examination of the spinal fluid usually shows an increased 
cell count and a positive Wassermann reaction. 
According to Plaut there are ten distinct syphilitic psychotic 
pictures: 
1. Simple Syphilitic Mental Enfeeblement.-This condition is 
found in persons who have suffered from monoplegia or hemi- 
plegia, and in the majority of instances occurs between the 
twenty-fifth and thirty-fifth years. There is a general impair- 
ment of the mental powers. Forgetfulness and indifference are 
the chief characteristics. 
2. Syphilitic Pseudo Paresis.-This condition very closely 
resembles paresis. Auditory hallucinations are characteristic. 
The examination of the spinal fluid and the general course of the 
disease differentiate it from true paresis. 
3. Syphilitic Paranoia.-This form occurs very frequently 
with tabes dorsalis. The patient entertains delusions of perse- 
cution and occasionally has auditory hallucinations and dis- 
turbances of smell and taste. The general mental powers are not 
much jmpaired. The patient is usually able to adjust himself 
to his environment. This condition persists quite a long time in 
certain individuals. 
4. Syphilitic Paranoia Occurring in the Absence of Tabes PSYCHOSES WITH CEREBRAL SYPHILIS 
99 
Dorsalis.-This form resembles the alcoholic psychoses. Delu- 
sions of marital infidelity are characteristic. 
5. Syphilitic Epilepsy.-In this form the convexity of the 
brain is generally involved. There is endarteritis of the small 
vessels of the cortex. If the larger vessels share in the process 
paralyses sometimes occur. This form is sometimes difficult to 
distinguish from true epilepsy. The Wassermann examination 
of the blood and spinal fluid will serve to make the differentia- 
tion. 
6. Transient States of Confusion Attended by Hallucinations. 
-The hallucinations may be of any form but are usually 
confined to the olfactory and gustatory types. This form very 
closely resembles the epileptic types of brain lues. 
7. Psychotic States Associated with Syphilitic Disease of the 
Heart or Aorta.-Here we find states of depression, irritability, 
restlessness, and periods of confusion. Distress in the chest and 
pain about the heart and down the left arm attend the mental 
symptoms. 
8. Manic Depressive States Due to Syphilis.-Periods of 
depression, elation and excitement are often observed. Asso- 
ciated with these are states of irritability and bizarre delusions. 
9. Psychogenetic States Due to the Morbid Fear of Syphilis.- 
There is a marked syphilophobia with its attendant symptoms, 
as described in the first portion of this chapter. 
10. Psychopathic States Due to Inherited Syphilis.-Indi- 
viduals of syphilitic inheritance present all manner of anomalous 
mental states ranging from imbecility to a fair degree of mental 
endowment associated with marked eccentricities. The signs of 
inherited syphilis are usually evident. 
Diagnosis.-It is at once apparent that it will be difficult in 
many instances to distinguish these more or less arbitrary 
groups from general paresis. Certain facts are to be borne in 
mind. Syphilis of the cerebral blood vessels occurs as a rule 100 
MANUAL OF PSYCHIATRY 
much earlier than paresis. The focal symptoms are more 
characteristic and prominent than in paresis. The nocturnal 
headaches which suddenly appear and disappear are character- 
istic of the syphilitic psychoses. Many times the differential 
diagnosis can be made only after the results of treatment have 
been observed. In paresis anti-syphilitic medication as a rule is 
unavailing. In the syphilitic psychoses there may be recoveries 
or very marked improvement except where there has been exten- 
sive destruction of the nervous elements. 
Treatment.-In every case very active anti-syphilitic treat- 
ment should be instituted. It must be borne in mind, however, 
that the patient is to be treated rather than the syphilis, and 
the treatment should be graduated, modified and regulated to 
suit the needs of the individual case. Mercury may be given by 
inunction, by mouth and by injection. Treatment by inunction 
gives better results than treatment by mouth. But inunction is 
uncleanly and takes time. The patient is very likely to take 
his treatment half-heartedly if he is not carefully watched. 
Another objection to the method is that secrecy cannot very 
well be observed. If mercury is employed by injection, the 
soluble and insoluble forms may be given, as preferred by the 
physician. The patient is very rapidly brought under the 
influence of mercury by the use of soluble salts, as bichloride, 
succinimide and cyanide. Cyanide of mercury may be given 
intravenously with good results. The patient should receive a 
course of injections varying from twenty to thirty if the indi- 
vidual doses range from a fourth to a half grain. The injections 
may be given intravenously every day, every other day, or twice 
a week. After five grains of mercury have been injected into 
either a vein or a muscle, the patient should be given a rest of 
thirty or sixty days and the treatment then continued according 
to his needs. 
Salvarsan and neo-salvarsan may be given along with the PSYCHOSES WITH CEREBRAL SYPHILIS 
101 
mercury or after the course of mercury is completed. From six 
to twelve injections of the neo-salvarsan should be given at a 
course. The doses should be of the minimum to begin with and 
increased until the point of toleration and the limit of safety have 
been reached. The injection may be given intraspinally, but 
this treatment has not been found to give any better results than 
the intravenous method. After the arsenical course has been 
completed the patient should have a rest of a month or sixty 
days and should then have another course of treatment. Bi- 
weekly examinations of the urine should be made to discover 
whether or not damage is being done to the kidney. A Wasser- 
mann test of the blood and spinal fluid should be made at 
frequent intervals, to regulate treatment and to note progress. 
The spirochetes seem to develop an immunity to both mercury 
and arsenic when either of these drugs is given alone, but this 
resistance of the syphilitic protozoa is destroyed by the mixed 
form of treatment. It is well to give potassium iodide through- 
out the course of treatment, in doses of from 15 to 60 grains 
three times a day, according to the needs of the patient. The 
potassium iodide should be well diluted with milk or water to 
avoid stomach symptoms. 
The rules of hygiene should be followed during treatment of 
the disease. Tonics and symptomatic medication are to be 
employed as the conditions demand. Daily hot baths, Turkish 
baths or weekly bakes in electric cabinets are of great benefit 
in promoting absorption and elimination of the antisyphilitic 
drugs. 
Those cases which cannot be controlled or safely cared for 
at home or in general hospitals should be committed to hospitals 
for the insane. CHAPTER X 
PSYCHOSES WITH BRAIN AND NERVOUS 
DISEASES 
Certain diseases of the brain and nervous system are accom- 
panied by a variety of psychotic symptoms. The most common 
of these diseases are the following: 
Brain Tumor 
Cerebral Embolism, Thrombosis and Hemorrhage 
Paralysis Agitans 
Meningitis, Tubercular or Other Types 
Brain Abscess 
Multiple Sclerosis 
Tabes Dorsalis 
Huntington's Chorea 
Sydenham's Chorea. 
Brain Tumor.-In addition to the nervous symptoms that 
attend brain tumor, such as headache, dizziness, vomiting, choked 
disc, interlacing of the color fields and slowing of the pulse, there 
has been observed in about two-thirds of all cases the develop- 
ment of psychotic symptoms. These are likely to occur if the 
tumor is located in the prefrontal region or in the anterior lobes 
of the cerebrum. Usually with the development of brain tumor 
there is a diminution of the mental powers, failure of the initia- 
tive, and forgetfulness. The patient loses his capacity for mental 
and physical work and often becomes drowsy and stuporous. At 
times he is very much confused and goes about in a dazed con- 
dition. Sometimes he assumes catatonic attitudes. Often he is 
grandiose, loquacious and euphoric. He is inclined to indulge 
102 PSYCHOSES WITH BRAIN AND NERVOUS DISEASES 
103 
in witticisms and sarcastic remarks. Blind patients suffering 
with brain tumor often have visual hallucinations. Tumors of 
the cerebellum occasionally produce mental symptoms of mild 
confusion and hysterical states. 
The mental symptoms occasionally obscure the diagnosis of 
brain tumor. Sometimes brain tumor is diagnosed as paresis 
and the reverse is true. The diagnosis of tumor is to be made 
by localizing the symptoms and by the evidences of choked disc. 
Paresis is to be ruled out by an examination of the blood and 
spinal fluid and a careful consideration of the nervous symptoms. 
Cerebral Embolism, Thrombosis and Hemorrhage.-Men- 
tal symptoms are frequently developed in these three conditions. 
The symptoms exhibited depend upon the portion of the brain 
affected; the type of nerve lesion will correspond to the local- 
ization areas involved. We may have speech disorders, any 
type of aphasia, or epileptoid convulsions. Hemiplegia is often 
present. The mental symptoms in general are those that have 
been described under the arteriosclerotic and senile insanities. 
There is generally failure of the mental powers, with emotional 
instability shown by marked irritability and states of depression. 
Periods of mild confusion often attend these conditions. Paresis 
attended by focal lesions is to be carefully ruled out. 
Paralysis Agitans.-The course of this disease is marked by 
a gradual impairment of the mental powers. Periods of depres- 
sion, states of mild confusion and hallucinations of sight, taste 
and smell are frequently observed. 
Meningitis, Tubercular or Other Types.-In tuberculosis 
we find patients exhibiting feelings of well-being out of all pro- 
portion to their physical state. Conditions of exaltation are 
frequently noted in dying tuberculous patients. More often the 
tuberculous patient is irritable, fault-finding and difficult to con- 
trol. He goes to excess in matters of exercise in his endeavor 
to regain his health. He is also given to alcoholic and sexual 104 
MANUAL OF PSYCHIATRY 
excesses. Delirious states are noted, which appear and disappear 
with the elevation and subsidence of fever. Periods of confusion 
are frequent, and they have been known to prelude physical 
symptoms. The confusion is usually attended by depressive and 
persecutory beliefs. When the disease invades the meninges the 
customary signs of tuberculosis meningitis are observed. It is 
to be remembered that dementia praecox is frequently associated 
with pulmonary tuberculosis. 
Brain Abscess.-Brain abscesses are often attended by psy- 
chotic symptoms which vary in degree and type with the location 
of the abscess and the character of the pus-producing organism. 
The patient is restless, delirious and confused. Convulsions are 
sometimes noted which are not easy to distinguish from those 
of epilepsy or hysteria. The history of the case and the localiza- 
tion of the nerve symptoms will be of assistance in the diagnosis. 
Multiple Sclerosis.-This disease is usually attended by a 
slow developing dementia. Auditory hallucinations and delu- 
sions of persecution are frequently noticed. Expansive ideas 
have been observed by some authorities. Great care must be 
exercised in differentiating this disease from paresis. 
Tabes Dorsalis.-The majority of tabetic patients maintain 
their mental integrity for the greater part. Many of them are 
able to follow vocations that require full functioning of the 
mental powers. If psychotic symptoms develop the disease has 
ascended the cord and attacked the cerebral cortex and a revision 
of the diagnosis is necessary, changing it to cerebrospinal syphilis 
or paresis, as the case may be. In order to secure relief from 
their pains tabetics often use alcohol, morphine, cocaine and 
other drugs to excess, therefore symptoms of drug psychosis are 
not uncommon. Any one of the essential psychoses may be 
added to the original disease of tabes dorsalis. 
Huntington's Chorea.-Associated with this disease are 
occasionally well-developed mental symptoms in addition to the PSYCHOSES WITH BRAIN AND NERVOUS DISEASES 
105 
gradual process of mental impairment. The patient becomes 
forgetful and easily irritated. At times he is confused. He often 
complains of auditory hallucinations. Occasionally he develops 
delusions of persecution and exhibits suicidal tendencies. 
Sydenham's Chorea.-Emotional instability, irritability, 
fretfulness and lack of patience are characteristic mental symp- 
toms of this disease. In addition to these usual states, there 
are frequently developed hallucinatory periods during which the 
patient suffers from insomnia and terrifying dreams. Occasion- 
ally there are periods of violence with states of confusion. 
Marked paranoid states have been observed, particularly in girls 
at the age of puberty. There are developed in rare instances 
stuporous conditions and states of exhaustion. Patients who 
have received excessive treatment sometimes show evidences of 
arsenic poisoning. 
Treatment.-In each instance the underlying brain or nervous 
disease is to be treated primarily and the psychotic disturbances 
should receive the necessary symptomatic medication in addition 
to physiotherapy, dietetic and hygienic measures and the indi- 
cated custodial care. CHAPTER XI 
PSYCHOSES DUE TO ALCOHOL, DRUGS AND 
OTHER EXOGENOUS TOXINS 
General Definition.-This is a group of psychoses resulting 
from the ingestion of narcotic and sedative drugs such as alcohol, 
opium or its derivatives, cocaine, chloral, bromides and veronal, 
and other exogenous poisons such as arsenic, mercury, lead and 
noxious gases. The chief symptoms produced by the use of these 
drugs and poisons are states of delirium and confusion, condi- 
tions of hallucinosis, paranoid reactions and mental deterioration. 
Alcohol.-The use of alcohol has been responsible for the 
production of about 20 per cent of all cases committed to insti- 
tutions for the insane. There is, however, a tendency on the 
part of the careless observer to overestimate the direct and 
indirect influence of this drug in the production of insanity. 
Not every psychosis associated with the use of alcohol should 
be regarded as an alcoholic psychosis, for alcoholism is often a 
symptom of the other essential psychoses. Its excessive use is 
frequently a part of the symptom complex of general paralysis, 
dementia praecox, manic-depressive insanity and epilepsy. 
Psychology of Alcoholism.-It has long been believed by 
the medical profession, as well as by the laity, that the ingestion 
of alcohol was followed by a brief period of stimulation lasting 
from a few minutes to an hour, depending on the amount taken 
and the personal resistance of the imbiber. Careful research 
concerning the phenomena of alcoholism has led to the following 
conclusions: Alcohol is not a stimulant. Alcohol is a sedative 
and paralyzant. The stimulation is apparent only and the sensa- 
tions of well-being and euphoria are due to psychic inhibition. 
106 PSYCHOSES DUE TO ALCOHOL 
107 
The processes of sensation and perception are rendered faulty 
and inaccurate. The physical worker and the student may have 
the subjective sensations that their muscular and mental powers, 
respectively, are increased for a brief time, whereas such is not 
the case. The feelings of physical and mental exhaustion are 
blunted and numbed only. As the condition of alcoholic paraly- 
sis increases, the psychic inhibition is further shown by a slowing 
down of ideation, failure of attention, rambling, incoherent con- 
versation, marked emotional irritability and disorders of conduct. 
The automatic functions next suffer in the paralyzing process. 
The patient becomes clumsy, staggers, reels and often falls. The 
speech becomes thick and indistinct. Finally the patient sinks 
into a sleep or even into coma. On awakening he is exhausted 
and distressed and the experiences of his debauch are for the 
most part forgotten or very hazily remembered. Conviviality 
and curiosity are often responsible for the formation of the liquor 
habit. Constitutional psychopathic inferiors and neurotics drink 
to "drown their troubles." They meet the painful realities of 
life by blunting their sensations and perceptions, or they seek 
unusual pleasures as they tire of the commonplace. 
There are at least twelve different types of psychoses or patho- 
logical reactions due to the use of alcohol. These reactions 
depend upon the personal equation and are an index to the cere- 
bral resistance. They are fairly definite and allow of clinical 
differentiation into the following group: 
Pathological Intoxication 
Delirium Tremens 
Korsakow's Psychosis 
Acute Alcoholic Hallucinosis 
Chronic Alcoholic Hallucinosis 
Acute Alcoholic Paranoia 
Chronic Alcoholic Paranoia 108 
MANUAL OF PSYCHIATRI 
Alcoholic Epilepsy 
Alcoholic Pseudo-Paresis 
Alcoholic Dream States 
Alcoholic Deterioration 
Dipsomania. 
Definition.-This is a state of morbid drunkenness which may 
follow the ingestion of either a large or a small amount of alco- 
holic liquor. 
Etiology.-Males are more frequently affected than females 
owing to the fact that men are more given to the use of alcoholic 
beverages. Some persons exhibit a marked susceptibility to the 
effects of liquor. Individuals of low mental capacity as a rule 
display a feeble resistance to the effects of alcohol. 
PATHOLOGICAL INTOXICATION 
Pathology 
Gross Pathology 
Congestion of the meninges 
Sub-pial hemorrhage. 
Microscopic Pathology 
Degenerative changes in cortical 
cells as shown by: 
Swelling of the nuclei 
Amalgamation of the Nissl granules 
Peripheral chromatolysis 
Distention of blood vessels 
Motor cells of the cord show simi- 
lar changes. 
The pathological changes enumerated have been found by- 
animal experimentation with alcohol, and in persons who have 
met accidental death during an acute state of drunkenness. 
Symptomatology.-Pathological intoxication is characterized 
by a marked period of restlessness, excitement and increased 
psychomotor activity, and occasionally by furore or frenzy. 
Hysterical conditions are common. The patient becomes con- 
fused and dazed. He may pass into a state of coma. Sometimes 
epileptic convulsions are observed. Disagreeable hallucinations 
and paranoid delusions often color the picture. The psychosis PSYCHOSES DUE TO ALCOHOL 
109 
is usually of short duration and the patient is very likely to 
have no memory of his conduct during the psychosis or but an 
indistinct recollection of it. 
Treatment.-Empty the stomach by the use of pump or 
apomorphine if the general condition of the patient warrants it. 
A thorough purge by calomel and a saline cathartic is then in 
order. During treatment the patient should be isolated and 
carefully watched. The heart should be examined from time 
to time. If coma develops, stimulation by drugs is to be em- 
ployed, together with the external application of heat and friction. 
DELIRIUM TREMENS 
Definition.-Delirium tremens is an acute psychosis usually 
associated with alcoholism. It is attended by disorders of con- 
sciousness, illusions and hallucinations of sight and hearing, 
restlessness, motor excitement, tremors, and ataxic disturbances. 
Etiology.-Males are more frequently affected than females. 
The disorder appears not to be due to alcoholism alone. It may 
develop weeks after the use of liquor has been discontinued. 
States of autointoxication due to constipation or dysfunction of 
the liver and kidneys are factors in its production. Chronic 
drinkers frequently develop this psychosis following trauma or 
infectious disease. 
Pathology 
Gross Pathology 
1. Venous stasis of cerebral vessels. 
2. Edema of the brain. 
3. Fatty degeneration of the heart 
muscle. 
4. Cirrhosis of the liver. 
5. Chronic interstitial nephritis. 
6. Hyperplasia of the spleen. 
Microscopic Pathology 
1. Degeneration of the cortical 
cells. 
2. Vacuolization of the cells. 
3. Increase in the glia. 
4. Atrophy of the radial fibers of 
the central convolution of the 
cerebellum. 
5. Destruction of the cortical and 
Purkinji cells. 110 
MANUAL OF PSYCHIATRY 
Symptomatology.-The onset of this disorder may be sudden 
or it may develop slowly, preceded by a prodromal period of 
insomnia, anorexia and general restlessness. The delirium is 
usually introduced by great excitement, confusion and incoher- 
ence of ideas. Marked tremor of the muscles is noted, particu- 
larly those of the face, tongue and hands, though all the muscles 
may be involved. As the disease progresses the excitement and 
confusion increase, the pulse becomes rapid and the skin hot 
and red and covered with profuse, disagreeable perspiration. 
Consciousness is often clouded and complete disorientation is 
occasionally encountered. Hallucinations of the most terrifying 
nature appear. The victim believes he sees snakes and reptiles 
of all sorts, complains of insects crawling under his skin, and 
picks at the bedclothes to rid them of vermin and mice. The 
patient hears voices threatening him with bodily harm, and car- 
ries on incoherent and wild conversations with imaginary foes. 
Often attempts are made to escape from his bed and room, and 
vicious and dangerous assaults upon his attendants are by no 
means uncommon. As the excitement and agitation increase 
the patient shouts and screams at the top of his voice until he 
is utterly fatigued. In some cases this motor agitation is absent. 
The symptoms are more acute at night than in the daytime. 
The patient's physical condition is one of exhaustion. The tem- 
perature may be slightly above normal and sometimes ranges 
from 100 to 103 degrees Fahrenheit. The pulse is rapid and 
feeble and precordial distress is common. Albuminuria is found 
in approximately 50 per cent of all cases, and in many instances 
leukocytosis has been observed during the height of the delirium. 
The disease generally lasts from three to five days and about 
90 per cent of all cases recover. In the favorable cases the 
delirium is terminated by a prolonged and restless sleep. In 
fatal forms the patient sinks into a profound coma and stupor 
which ends in death. PSYCHOSES DUE TO ALCOHOL 
111 
Treatment.-Isolation and custodial care, rest in bed, light, 
nutritious food. There should be symptomatic medication to 
overcome restlessness, excitement and insomnia. Prolonged 
warm baths may be judiciously employed for the same purpose. 
The heart should be regularly examined and cardiac stimulants 
used as indicated. 
KORSAKOW'S PSYCHOSIS 
Definition and Etiology.-This is a psychosis which is often 
developed upon the basis of chronic alcoholism, but it may owe 
its origin to other toxic states due to infectious diseases such as 
tuberculosis, influenza, diabetes, typhoid fever and metallic 
poisons. It may or may not be accompanied by a polyneuritis. 
It occurs in either a delirious or a non-delirious form. In the 
non-delirious form there are disturbances of orientation, marked 
susceptibility to external stimulation and suggestion, and falsifi- 
cation of memory. The delirious type somewhat resembles 
delirium tremens. 
Pathology 
Gross Pathology 
Gross evidences of degenerative 
changes in the 
Cortex 
Basal ganglia 
Spinal cord and 
Peripheral nerves 
Acute hemorrhagic encephalitis. 
Microscopic Pathology 
Degenerative changes in the cortical 
cells 
Minute hemorrhages in the central 
gray matter 
Degenerative changes in the nerve 
fibers of the central convolutions 
Atrophy of the nerve fibers in the 
column of Goll 
Degenerative changes in the peri- 
pheral nerves. 
Symptomatology.-The symptoms usually appear after an 
alcoholic debauch or follow a state of delirium tremens. The 
power of attention is markedly disordered, as are orientation 
and memory. The memory defect is peculiar, inasmuch as the 
patient fills in the lapses of memory with all manner of untrue 112 
MANUAL OF PSYCHIATRY 
statements which are related with apparent clearness of mind. 
A bedridden patient will tell the examiner the most marvelous 
stories of adventure and activity in which he has just been 
engaged. The patient is highly susceptible to suggestion and 
will invent fabrications to fit the occasion when stimulated by 
being questioned. Various forms of Korsakow's psychosis have 
been designated, depending upon the predominating symptom. 
In some the chief symptom is forgetfulness; in others, confu- 
sional states are most marked. Delusional tendencies are the 
chief traits of other forms. Some patients exhibit marked states 
of anxiety, and conditions of dementia have been found. 
Physical Symptoms.-The patient generally shows the signs 
of polyneuritis, such as wrist drop, foot drop, hyperesthesia, 
aphasia, incoordination, positive Romberg, unequal pupils and 
occasionally Argyll-Robertson pupils. 
Diagnosis.-Falsifications of memory, disorientation, wrist 
drop, and a history of alcoholism or infectious disease make the 
diagnosis easy after general paresis has been ruled out by a 
Wassermann examination of the blood and spinal fluid. 
Treatment.-Withdrawal of alcoholic beverages where these 
are the cause, free elimination by catharsis and diuresis, rest in 
bed during the acute stage. The diet should be light and nutri- 
tious. Warm baths, massage, passive movements and gymnastics 
should be employed in the later stages to overcome or improve 
muscular disabilities. Tonic medication should be given as 
indicated. 
ACUTE ALCOHOLIC HALLUCINOSIS 
Definition.-This is an acute psychosis which frequently de- 
velops in chronic alcoholics. It may come on suddenly after a 
debauch or it may have a slow onset. It often follows an attack 
of delirium tremens. It is characterized chiefly by auditory PSYCHOSES DUE TO ALCOHOL 
113 
hallucinations and loosely woven delusions of persecution. As 
a rule consciousness is not much disturbed. 
Etiology.-Alcoholic excesses and abstinence from food dur- 
ing periods of debauch. Males are more frequently affected than 
females. In the majority of instances the disease occurs in 
middle life. About 50 per cent of the alcoholic psychoses found 
in hospitals for the insane are of this type. 
Mental Symptoms.-The primary symptoms are auditory 
hallucinations of a disagreeable nature. The patient hears 
voices accusing him of sexual acts such as rape, incest, sodomy 
and masturbation. These voices seem to come out of the air, out 
of the walls, from radiators, from clocks, or from any object 
within the environment. Hallucinations of taste and smell 
are frequent and the patient often complains of disagreeable sub- 
stances in the air, water or food. Visual hallucinations are 
rarely present. 
The delusions entertertained by the patient are of a disagree- 
able, persecutory nature, as are the hallucinations. The sub- 
ject of this disease often believes his food is poisoned by his 
enemies in order to produce nocturnal emissions. He may be- 
lieve that his wife is unfaithful to him or that his children and 
relatives seek his misfortune. His conduct is so ordered by 
these painful and delusional beliefs that occasionally vicious 
assaults are made upon his supposed enemies. 
In some cases great depression accompanies the delusions and 
hallucinations, and as a result attempts at suicide are not infre- 
quent. Anxious states and ideas of impending danger are oc- 
casionally noted, but conditions of elation and euphoria are 
rarely seen. Consciousness remains fairly clear in most cases 
and orientation is not usually disturbed. 
Physical Symptoms.-These are quite characteristic. Insom- 
nia and headaches are marked. The patient loses weight by rea- 114 
MANUAL OF PSYCHIATRY 
son of his restlessness, lack of food and loss of sleep. Tremors 
of the tongue, face and body muscles are frequent. The re- 
flexes as a rule are increased. 
Course and Prognosis.-This depends largely on the physical 
condition of the patient. The usual duration is from ten to 
fifteen days. In asthenic subjects the course is prolonged and 
may become sub-acute, and in this class of cases the prognosis 
is guardedly favorable. This is especially true when the psy- 
chosis is attended by acute infectious diseases such as pneumo- 
nia or erysipelas. 
Diagnosis.-In delirium tremens the predominating halluci- 
nations are usually of a visual character. Orientation is more 
likely to be disordered in delirium tremens than it is in alcoholic 
hallucinosis. 
In dementia praecox the development of the psychosis is 
more gradual. There is considerable evidence of mental de- 
terioration and there are states of negativism, mutism and cata- 
tonia. Marked emotional indifference is characteristic of de- 
mentia prsecox, whereas the emotional depression of alcoholic 
hallucinosis is decidedly painful and distressing. 
In general paresis we have the customary neurological signs 
and marked dilapidation of the mental powers. 
In paranoia the delusional system is very slowly developed 
and in many cases the history of prolonged alcoholic excesses 
may be ruled out. 
Treatment.-Alcohol should be withdrawn altogether. The 
insomnia should be combated by the use of hydrotherapy in 
the form of hot and cold showers, prolonged tub baths, warm 
packs, and the employment of bromides, chloral and other seda- 
tives. The heart should receive careful attention and strychnine 
and digitalis should be employed as indicated. The diet should 
be nutritious but of a light character. PSYCHOSES DUE TO ALCOHOL 
115 
CHRONIC ALCOHOLIC HALLUCINOSIS 
This is to be regarded as a sub-acute form of the acute al- 
coholic hallucinosis. It is rather infrequently observed. The 
symptoms in the main are essentially the same as in the acute 
form, except that the emotional states of anxiety, distress and 
apprehension are less marked and disturbances of conduct more 
rare because of the lessened emotional response to the hallucina- 
tions and delusions. 
ACUTE ALCOHOLIC PARANOIA 
This is a paranoid state developing upon the chronic use of, 
alcohol, attended by delusions of persecution which relate to 
marital infidelity and jealousy. The patient entertains all sorts 
of delusions of infidelity concerning his wife. He interprets the 
simplest acts of social and business intercourse to be bona fide 
evidences of adultery on the part of his mate. He watches the 
mail carrier when he delivers the mail, is suspicious of the grocer, 
of his neighbors, of street car conductors, or of any person who 
may have the most trifling social or business relations with his 
wife. The patient ceases to care for his children because he 
thinks they are the offspring of his wife's paramour. Hallucina- 
tions are quite common. The patient hears his enemies talking 
about him. The noises about his home, in the factory, in his' 
office, or wherever he may be, are interpreted to be voices which: 
speak evil of him. Hallucinations of smell are common. He be- 
lieves that noxious odors are introduced into his room. For this 
reason he plugs up keyholes and cracks in the windows. Again,' 
he may believe that his food is poisoned and take his meals at 
a restaurant rather than at home, for fear his wife and her; 
lover may attempt to poison him. As a rule consciousness red 
mains clear. Reason and judgment are impaired. Many times 
the patient's behavior is not in harmony with his expressed def. 116 
MANUAL OF PSYCHIATRY 
lusional beliefs, for he may continue to live in peace with 
his family in spite of the delusions of infidelity and persecution. 
Course and Prognosis.-The delusional beliefs usually 
remain fixed in the patient's mind, but the emotional responses 
are lessened when the individual is placed in a quiet environ- 
ment and alcohol is withdrawn. Because of this the relatives 
and friends of the patient are often led to believe that a perma- 
nent cure has been effected. If the patient is placed in irritating 
circumstances or environments or again resumes the use of al- 
coholic liquor, the symptoms recur. 
Diagnosis.-Sometimes the diagnosis is fairly difficult because 
the chronic use of alcohol leads to the disruption of home and 
marital ties, and the conduct of the marital mate may be such 
as to suggest that the patient has some foundation for his de- 
lusional beliefs. He may be able to present arguments for his 
beliefs in a fairly logical manner and the mental deterioration 
may be of the slightest degree, so that his deductions and con- 
clusions may sound quite reasonable. Careful consideration 
of the case and investigation of the circumstances will generally 
show whether the beliefs have a morbid basis. When actual in- 
fidelity does occur the patient is often quite indifferent. 
In dementia prsecox we occasionally encounter delusions of 
jealousy and infidelity, but the delusional beliefs are not pre- 
sented as logically and reasonably as they are in alcoholic par- 
anoia. The withdrawal of alcohol results in a subsidence of the 
symptoms in the alcoholic disease, which is not the case in de- 
mentia praecox. 
True paranoia is usually of slow development and the delu- 
sions of persecution are more systematized and are not affected 
by the withdrawal of alcohol. 
Treatment.-Immediate withdrawal of alcohol and the plac- 
ing of the individual in a private or state institution where he PSYCHOSES DUE TO ALCOHOL 
117 
may be carefully watched to prevent assaults and attacks upon 
innocent persons. 
CHRONIC ALCOHOLIC PARANOIA 
This disease may take on a sub-acute form and the delusions 
of persecution and infidelity may persist after the withdrawal 
of alcoholic liquors. 
ALCOHOLIC EPILEPSY 
Frequently convulsions occur in chronic alcoholics, scarcely 
distinguishable from the convulsions of idiopathic epilepsy. 
Upon withdrawal of alcohol the epileptoid convulsions cease. 
ALCOHOLIC PSEUDO-PARESIS 
The chronic use of alcohol is frequently attended by a state of 
mental deterioration which is associated with marked disorders 
of the tendon and skin reflexes, with anomalies of the pupils, 
disorders of speech, disorders of locomotion, tremors and transient 
paralyses. Clinically it is extremely difficult to differentiate this 
condition from true paresis, for the paretic is often given to al- 
coholic excesses. In making a diagnosis a careful history must be 
obtained. The onset of paresis is usually slower. In alcoholic 
pseudo-paresis the signs of polyneuritis are commonly found, 
while in paresis these symptoms are relatively rare. The Was- 
sermann of the blood and spinal fluid is usually positive in 
paresis, and the cell count is usually increased and the globulin 
test positive. Paresis is progressive and ends in death, while the 
course of alcoholic pseudo-paresis may be arrested, at least to 
some degree, by the withdrawal of alcohol. Alcoholic pseudo- 
paresis usually terminates in a state of alcoholic dementia. 
ALCOHOLIC DREAM STATES 
The following mentioned conditions may occur as a result of 
the excessive or prolonged use of alcoholics: automatism, som- 118 
MANUAL OF PSYCHIATRY 
nambulism, amnesia, dual personality and catalepsy. In these 
conditions the alcoholic individual may take long journeys, 
engage in his usual occupations, make business transactions, and 
even commit crimes. When these states have passed the individ- 
ual has no memory of what may have occurred during their ex- 
istence. Cases of this sort often furnish the basis for medico- 
legal contentions. 
ALCOHOLIC DETERIORATION 
This is a state of insidious, progressive mental enfeeblement 
attended by impairment of memory, emotional deterioration and 
instability, lack of power of application to work, and impair- 
ment of reason and judgment. Occasionally hallucinations and 
delusions are developed. 
Etiology.-Chronic alcoholism is usually an evidence of a 
defective nervous organization. At least 50 per cent of chronic 
alcoholics are the offspring of tainted stock. Occasionally in- 
juries to the head, spine or other portions of the body may pre- 
cipitate the chronic use of alcohol. Males are more often affected 
than females. Social customs and conviviality have no doubt 
been responsible for the development of chronic alcoholism in 
individuals of unstable nervous systems. 
Pathology 
Gross Pathology 
1. Reduction in brain weight. 
2. Leptomeningitis. 
3. Pachymeningitis. 
4. Shrinking of the convolutions. 
5. Dilatation of the ventricles. 
6. Sclerosis of the cerebral blood 
vessels. 
7. Endarteritis. 
8. Cirrhosis of the liver. 
9. Chronic nephritis. 
10. Chronic gastritis. 
11. Myocardial degeneration. 
12. General arteriosclerosis. 
Microscopic Pathology 
1. Increase of neuroglia. 
2. Degenerative changes in the 
nerve cells. 
3. Destruction of nerve cells. PSYCHOSES DUE TO ALCOHOL 
119 
Symptomatology.-There is a gradual change in the habitual 
drinker's character and mental capacities. He finds it difficult 
to apply himself to his usual daily labor, cannot concentrate his 
mind as formerly, shows a lessened capacity for attention to de- 
tail, and cannot acquire information. The memory fails, reason 
and judgment become markedly impaired, and because of his 
failure to conceive circumstances in their true relations delusions 
are developed. Due to faulty perceptions, hallucinations are 
occasionally encountered. There is a marked change in the 
moral characteristics of the individual. A formerly goodnatured 
person becomes morose, sullen, and given to outbreaks of temper. 
He ceases to care for his personal appearance; is dirty and un- 
kempt. His clothes are not properly fastened and arranged and 
are often stained with food. His sense of honor is lost; he is 
given to lying. At times he is ready with promises to cease 
indulgence in liquor, but he straightway forgets his promises. 
He invents all sorts of excuses to use alcohol; says that it is 
necessary for the continuance of his daily labor; that he takes 
it to keep him warm, or if his work is in foundries or bakeshops, 
that he takes it to keep cool. Disappointments and failures in 
business are given as excuses for alcoholic indulgence. The 
economic and social degradation of his family are of little mo- 
ment to him. His mental incapacity in time becomes so great 
that he is unable to carry on his usual occupation. He sinks 
lower and lower in the social scale, and in order to get liquor 
will pawn his belongings and steal the property of others. 
Physical Symptoms.-The physical condition of the chronic 
alcoholic usually proclaims his use of the drug. The capillaries 
of the face are prominent and distended, the face is usually 
flushed and purple and the nose may be markedly reddened. 
Occasionally extreme pallor of the face is found. There is tremor 
of the facial muscles and general muscular weakness. The gait 
is shambling and slovenly, the speech is generally thick and de- MANUAL OF PSYCHIATRY 
120 
fective, and symptoms of peripheral neuritis are often present. 
The patient complains of formications, numbness and tinglings 
about the body. The course of the nerves may become painful. 
Convulsive attacks occur in about 15 per cent of all cases. 
Course and Prognosis.-The course is usually chronic and 
is in ratio to the amount of mental deterioration present. The 
more marked the mental dilapidation the less hope for recovery. 
About 25 per cent of chronic alcoholics make social recoveries 
if they are placed in institutions for long periods of time. 
Diagnosis.-The history of the case and the typical mental, 
physical and moral degeneration make the diagnosis fairly cer- 
tain and easy. 
Treatment.-The use of alcohol should be immediately 
stopped. The patient should be placed in an institution and 
isolated from his friends and family. The sudden withdrawal 
of alcohol may be attended by symptoms of collapse, anorexia, 
insomnia and extreme nervousness, but this condition can be 
readily met by the employment of heart stimulants, bitter tonics 
containing capsicum, and other mild stimulants. The diet should 
be light and nutritious. The emunctory organs should be kept 
active. Daily baths are beneficial. Psychotherapy is of advan- 
tage in many cases. The patient should be encouraged and 
strengthened to meet his alcoholic temptations. This can best 
be done by the method of psychoanalysis. 
DIPSOMANIA 
Definition and Etiology.-Dipsomania is the periodic indul- 
gence in alcoholic beverages, due to morbid, irresistible impulses, 
occurring in persons of constitutionally inferior makeup. 
Pathology.-There is no demonstrable pathology. 
Symptomatology.-The victim of this disorder drinks because 
he is mentally abnormal, whereas the chronic alcoholic becomes 
mentally affected because he drinks. For months the dipsoma- COCAINISM 
121 
niac refrains completely from the use of alcohol. Then suddenly 
he goes on a terrific alcoholic debauch, during which he will drink 
alcohol in any form in which he can procure it, including hair 
tonics, perfumes, flavoring extracts or any substances containing 
alcohol. During this time he gives himself up entirely to the 
satisfying of his intense morbid cravings, to the complete neglect 
of his business and his family. Usually he stops his spree as 
precipitately as he started it, but there may be a tapering-off 
process lasting several days. 
Treatment.-The attack may occasionally be warded off if 
the patient will notify his friends in time to institute abortive 
measures such as rest from work for a few days, change of 
scenery, thorough catharsis with calomel followed by a saline 
purgative, warm baths and showers and careful administration 
of bromides to secure sedation and sleep. Once the spree is 
started it seems that it must run its course. At its termination 
the patient should be given a vigorous cathartic, hydrotherapy in 
the form of Turkish baths and hot and cold showers, and bro- 
mide therapy and other symptomatic medication as needed. 
COCAINISM 
Definition.-Cocainism is a state of intoxication produced by 
the excessive or habitual use of cocaine or other alkaloid of 
erythroxylon coca. This drug is seldom used alone and often in 
combination with alcohol and morphine, so that the clinical pic- 
ture is not always clear cut or unmodified. 
Etiology.-The cocaine habit is sometimes formed when 
cocaine has been incautiously used in the treatment of morphin- 
ism. It would seem that the use of cocaine is increasing, but 
this has not yet been proven. About 80 per cent of individuals 
who use this drug have previously used alcohol or morphine, 
and the histories of about 75 per cent of users show the evidences 
of tainted heredity. The drug is taken by means of a hypo- 122 
MANUAL OF PSYCHIATRY 
dermic needle and by mouth, and it is a frequent practice 
among criminals, vagrants and prostitutes to snuff it from the 
back of the hand into the nares. The latter method often pro- 
duces a marked catarrh and occasionally an ulcerated condition 
of the mucous membrane of the nose. 
Pathology.-There is no characteristic pathology. 
Symptomatology.-The mental symptoms of cocainism differ 
but little from those of morphinism. The action of cocaine is 
more rapid than that of morphine, and the feeling of wellbeing 
and contentment is more pronounced, but the period of euphoria 
is shorter. The pupils are usually dilated, the pulse rate 
is increased, the patient is hilarious and talkative and exceed- 
ingly goodnatured, and his general behavior indicates that he is 
under the influence of some drug. 
The first manifestation of the chronic use of cocaine is a con- 
dition of extreme restlessness followed by a period of irritability. 
The patient's behavior becomes erratic and his conversation inco- 
herent and irrelevant. The will power is weakened, the moral 
sense becomes dull and perverted and the victim is given to 
lying and stealing. He occasionally commits crimes and mis- 
demeanors of a sexual nature. States of mental confusion at- 
tended by somatic delusions and hallucinations are common. 
The patient often complains of worms and bugs crawling under 
his skin. This particular form of paresthesia is known as the 
"cocaine bug." Delusions of infidelity are quite common. Often 
the patient believes that his personal rights are not respected; 
that his enemies follow him about the streets. Many other sim- 
ilar paranoid ideas are encountered. 
The continued use of cocaine is attended by a condition of 
weakness, emaciation and anemia. The skin is usually cachexic. 
Needle scars are found in various parts of the body. Often scars 
of old abscesses, due to the use of an unsterilized needle, are 
found. The pulse is usually weak and rapid. Nystagmus is a MORPHINISM 
123 
frequent symptom. The pupils are generally dilated and the 
eyes unusually bright. The sudden withdrawal of the drug from 
an individual who has long used it may produce a condition of 
marked nervousness, great physical distress, vomiting and head- 
aches, attended by a paranoid state during which the individual 
is potentially dangerous. 
Course and Prognosis.-The majority of cocaine users are 
individuals of unstable nervous systems, and for this reason 
permanent recovery is not usual. 
Treatment.-The individual should be placed in an institu- 
tion or in an environment where he can be absolutely controlled. 
The drug should be withdrawn at once, provided no symptoms 
of collapse present themselves. The tapering method of with- 
drawing the drug is not successful. With this method, as soon 
as the drug has been reduced to the smallest amount the patients 
have an apparent recurrence of their former symptoms and the 
"cure" has to be repeated. The heart should be carefully 
watched and heart stimulants such as strychnine, camphor and 
alcohol should be given if their use is indicated. Insomnia may 
be overcome by the judicious use of bromides and small doses of 
veronal, chloral or trional in combination with prolonged warm 
baths. The diet should be light and nutritious. The individual 
should be confined long enough to enable him to recruit his moral 
powers against relapses. 
MORPHINISM 
Definition.-Morphinism is a chronic intoxication which 
develops in the habitual users of opium or its alkaloids. 
Etiology.-The morphine habit is formed in neuropathic 
individuals who resort to the use of the drug for the relief of 
physical pains such as those which occur in locomotor ataxia, 
persistent neuralgia and rheumatism, or to overcome prolonged 
fatigue, worry and insomnia. The formation of the habit in 124 
MANUAL OF PSYCHIATRY 
persons of a certain class is due to curiosity and an appetite for 
new sensations, and to the train of pleasant symptoms which 
follow the first use of morphine. Morphinism is about equal in 
the two sexes. In rare instances physicians are no doubt respon- 
sible for the formation of this habit, through use of the too ready 
hypodermic needle. It is a regrettable fact that about 15 per 
cent of the habitues of this drug are physicians, dentists, phar- 
macists and professional nurses. About 50 per cent of the users 
of this drug are individuals of unstable nervous organizations. 
Pathology.-The pathology is not characteristic. Vascular 
congestion of the brain and its membranes with serus effusion 
into the ventricles have been found in those who have died from 
opium poisoning. The cerebral cortex is shrunken and anemic. 
There is an increase of the neuralgia. The heart muscle shows 
degenerative changes. 
Symptomatology.-The use of morphine or its alkaloids is at 
first followed by a state of mild euphoria, but as the habit be- 
comes intensified increasing doses must be taken in order to pro- 
duce a feeling of wellbeing. In the course of the disease the 
pleasant sensations are lost and a condition of depression fol- 
lows. This condition the victim tries to alleviate by a further 
increase of the dosage of the drug. Instead of finding relief he 
soon learns that the larger doses serve only to increase his mental 
depression and the other symptoms which he seeks to alleviate. 
As the habit progresses the symptoms become more marked and 
distressing. The patient's mental powers become feeble; he is 
unable to concentrate and is easily fatigued mentally. Losses of 
memory are common, and hallucinations and delusions occur. 
The emotions are unstable and are subject to alterations be- 
tween depression and elation. States of irritability are observed 
and the sleep is disturbed by terrifying dreams. The moral 
qualities of the mind suffer in the deteriorative process. The 
will power is weakened and a propensity for lying and stealing MORPHINISM 
125 
is exhibited. Sexual crimes are not uncommon. It is a common 
practice for the patients to sleep during the daytime and remain 
awake and restless at night. They are talkative, faultfinding, 
critical and obstinate. They supplement the use of morphine 
with alcohol. They are unable to follow their usual occupations 
because of the impairment of their mental powers. 
Physical Symptoms.-The patient loses his appetite; suffers 
from attacks of gastralgia. Periods of diarrhoea are observed 
in many instances, and loss of weight and strength progress with 
the advance of the disease. Disturbances of the visual powers 
are often noted. The pupils are usually much contracted. The 
patellar reflexes are often absent. Headaches and vertigo are 
constant symptoms and albuminuria and glycosuria due to 
transient renal congestion is seen in some cases. Itching is fre- 
quent after the taking of morphine or opium. Insomnia is a 
usual symptom. Patients often fill their nights with the making 
of plans to obtain the drug and wild schemes to procure money. 
Hallucinations of sight frequently occur at night. Patients com- 
plain of vertigo, dizzy attacks and headaches. 
Course and Prognosis.-Individuals of robust constitution 
can withstand the ravages of this disease for a fairly long time 
before there are marked signs of impaired mental and physical 
health. Less vigorous persons of asthenic constitution may die 
of malnutrition and inanition or heart failure in the course of 
twelve months. Occasionally individuals die from an overdose 
of morphine, but this is rare, because the increase of the dose is 
usually gradual. Death has sometimes followed the abrupt with- 
drawal of the drug. The prognosis is unfavorable in about 90 
per cent of the cases. There may be temporary improvement on 
abstinence from the drug, but the patients relapse whenever an 
opportunity to secure the drug affords itself. 
Diagnosis.-This can usually be made from the history of 
the case. Individuals who present alternate periods of excessive 126 
MANUAL OF PSYCHIATRY 
wellbeing and depression without apparent cause, are to be re- 
garded with suspicion. It must be borne in mind that the victim 
of this disease will practice all manner of deceit to hide his habit. 
In the case of women it is well to remember that the vagina has 
been used to hide the drug and hypodermic needle. The use of 
the drug may be detected by the examination of the urine and 
the stomach contents. The skin usually has a yellowish-gray 
appearance and the pupils are of the pinpoint variety. The 
body should be carefully examined for evidences of the use of 
the hypodermic needle. 
Treatment.-Three methods may be employed in the treat- 
ment of morphinism so far as the withdrawal of the drug is 
concerned. 
First.-The abrupt withdrawal of the drug. This method as a 
rule can be followed with robust individuals. In vigorous persons 
mental symptoms and physical collapse rarely follow this 
practice. 
Second.-The rapid withdrawal of the drug. The drug is re- 
duced each day by graduated amounts for six or seven days until 
its use is entirely discontinued. 
Third.-The slow withdrawal of the drug. In this method the 
amount of the drug taken is reduced gradually from day to day. 
This method is applicable in the treatment of very weak and 
emaciated patients or those who suffer from chronic, incurable 
or painful diseases such as tabes dorsalis, brain tumor and cancer. 
It is imperative that these cases should be isolated and that 
strict supervision should be maintained by trustworthy attend- 
ants to prevent the patient from securing the drug. The diet 
should consist of easily digestible, nutritious food; the patient's 
strength should be supported by tonics (elixir of iron, quinine 
and strychnine may be used to advantage). Bromides may be 
employed to relieve any unpleasant symptoms that follow the 
withdrawal of the drug. Sulfonal, veronal and paraldehyd are 127 
PSYCHOSES DUE TO DRUGS AND METALS 
useful in combating insomnia. Massage, baths and graduated 
exercise are useful in the convalescent stage. Psychotherapy is 
of great value in the treatment of these cases. 
PSYCHOSES AND PSYCHOTIC STATES DUE TO OTHER 
DRUGS AND METALS 
Psychotic disturbances have followed the temporary or chronic 
poisoning with various drugs and metals. The list is long, but 
since the mental disturbances have outstanding symptoms in 
common, they will be described as a whole, very briefly. 
The most prominent among these poisons are veronal, sulfonal, 
trional, luminal, chloral hydrate, paraldehyd, chloroform, ether, 
phenacetin, antipyrin, chloralamid, belladonna, atropin, hyos- 
cyamus, hyacine, quinine, iodiform, santonin, carbonic acid gas, 
mercury, lead, arsenic and bromides. 
The general symptoms of these acute intoxications are dream- 
like states, delirious conditions, disturbances in the psycho- 
sensory field, bizarre delusions, auditory hallucinations, changing 
emotional states (from one of good humor to one of irritability) 
and conditions of motor excitement. 
The predominant symptoms of the more important poisonings 
will be mentioned. 
Lead Poisoning.-This condition is characterized by head- 
aches, restlessness, delirium, visual hallucinations, delusions of 
persecution, clouding of consciousness and convulsive attacks 
which resemble those of epilepsy. 
Physical Signs.-There is marked tremor of the body mus- 
cles in general, twitching of the muscles of the face, inarticulate 
speech, insomnia which is often followed by clouding of con- 
sciousness, and coma. There is often wrist drop and ankle drop, 
atrophy of the muscles of the hand, the steppage gait, and in- 
complete or complete paralysis of the legs. This condition fre- 
quently occurs in lead workers. 128 
MANUAL OF PSYCHIATRY 
Chloroform Intoxication.-A dreamlike state is produced by 
the chronic use of chloroform and hallucinations of sight are 
common. 
Santonin Poisoning.-In chronic poisoning of this drug vis- 
ual hallucinations develop, and all objects within the field of 
vision appear to be yellow. 
Cannabis Indica Poisoning.-In this condition there is pro- 
duced a dreamlike state in which the patient has phantastic but 
usually pleasant hallucinations. The muscle sense is usually dis- 
ordered, as is the sense of taste. 
Carbonic Acid Gas Poisoning.-The mental disturbances 
are of short duration and are accompanied by hallucinations of 
a sexual nature. 
Belladonna and Atropin Poisoning.-The poisoning is 
characterized by delirious states, great motor restlessness and 
states of euphoria. In some instances the patient is very much 
depressed. Psychotic disturbances are of very short duration, 
as the individual either promptly recovers or dies from the 
intoxication. 
Veronal Poisoning.-The patient develops a dreamlike state 
and often goes into a profound stupor which occasionally ends 
in death. Often the patient is greatly incoordinated. He stum- 
bles and staggers about like a drunken man and talks in an ir- 
relevant manner. The pupils are widely dilated. 
Bromide Poisoning.-A dreamlike state is produced which 
is often attended by delirium. The patient is usually disoriented 
in one or more spheres. As a rule there are delusions of persecu- 
tion, reference and influence, and auditory hallucinations are 
frequent. The patient is given to falsifications. 
Chronic Arsenical Poisoning.-This occurs in individuals 
who work with dyes in the manufacture of colored paper and 
textiles. It is attended by paralysis similar to that of lead 
poisoning with the exception that the lower extremities are more PSYCHOSES DUE TO DRUGS AND METALS 
129 
often affected than the upper. There is the usual steppage gait, 
and weakness of the wrists and fingers. Tingling and numb- 
ness of the extremities is common. The chief mental symptoms 
are states of delirium, confusion, headaches, malaise and gid- 
diness. 
Treatment.-This should consist in the immediate withdrawal 
of the drug or metal and the application of the physiological or 
chemical antidote. There should be free elimination by flushing 
of the bowels, kidneys and skin, and hydrotherapy in the form of 
prolonged baths and hot packs. The patient's strength and 
vitality are to be supported by appropriate tonics, and seda- 
tives are to be judiciously employed to control delirium and in- 
somnia if hydrotherapy is not sufficient to accomplish this. The 
course of these intoxications is from a few days to several months. CHAPTER XII 
PSYCHOSES WITH SOMATIC DISEASES 
Definition.-Within this group are included the psychotic 
states which attend the infectious diseases, constitutional dis- 
orders, states of exhaustion and diseases of the endocrine glands. 
With respect to their etiology and symptoms they are classified 
as follows: 
Delirium with Infectious Diseases 
Post-Infectious Psychoses 
Exhaustion Delirium 
Delirium of Unknown Origin 
Cardio-Renal Disease 
Disease of the Ductless Glands 
Other Diseases or Conditions to be Specified, Which 
Include 
a. Diabetes. 
b. Gout. 
c. Gastrointestinal disorders. 
d. Pellagra. 
e. Rheumatic fever. 
f. Malaria. 
g. Pregnancy, parturition, puerperium and lactation. 
h. Influenza. 
i. Lethargic encephalitis. 
Etiology.-The factors in the production of these psychotic 
states are the 
Resistance of the patient. 
130 PSYCHOSES WITH SOMATIC DISEASES 
131 
Degree of temperature elevation. 
Virulence of the infecting organism. 
Of these three, the most important factor is the condition of 
instability and lack of resistance of the nervous system. An 
individual's mental stamina is ofttimes measured by the re- 
sistance which his nervous system offers to infectious diseases. 
Women and children develop the infection psychoses more often 
than men, but individuals of both sexes who are delicately or- 
ganized are equally susceptible. A very slight temperature is 
sufficient to produce confusion and delirium in some individuals, 
while others are able to withstand temperatures above 104 with- 
out the slightest exhibition of mental symptoms. Infectious dis- 
eases attended by the formation of pus are much more likely 
to produce psychotic symptoms. 
Pathology 
Gross Pathology 
The gross pathology is that which 
is characteristic of the disease pro- 
ducing the psychotic symptoms. 
For instance, at autopsy we find the 
morbid anatomy of pneumonia 
and nephritis. 
Microscopic Pathology 
There are found degenerative 
changes in the cortical cells. Some- 
times the absence of these cells is 
noted, and a condition is observed 
which is similar to the morpholog- 
ical nerve changes in animals which 
have been subjected to excessive 
heat. 
Symptomatology.-According to the time of appearance of 
the symptoms which are associated with these diseases they are 
classified as prefebrile, febrile and postfebrile. 
DELIRIUM WITH INFECTIOUS DISEASES 
Prefebrile Delirium.-Early in the stages of febrile diseases, 
even before fever has become manifest or before the temperature 
has been elevated more than a degree, psychic disturbances de- 
velop. The symptoms are due to the action of bacteria or to the 
action of other toxic agents. The chief mental manifestations 132 
MANUAL OF PSYCHIATRY 
are headache, malaise, confusion, delirium, transient hallucina- 
tions and changeable delusions of a disagreeable nature, irritabil- 
ity, and states of depression or excitement. To the ensemble 
of these symptoms the term initial delirium has been applied. 
Occasionally typhoid fever is first evidenced by psychotic symp- 
toms of the type just described. 
Febrile Delirium.-The symptoms of this form attend the 
febrile period of the disease and usually correspond in intensity 
and character to the temperature curve. In cases where only a 
slight degree of pyrexia is present, symptoms are nocturnal in 
their appearance and take the form of illusions, hallucinations, 
conditions of confusion and restlessness. In states of hyper- 
pyrexia there are conditions of pronounced clouding of conscious- 
ness, disorientation in all spheres, disagreeable hallucinations 
and delusions, and great restlessness and excitement. If the 
fever rises the symptoms are intensified. The patient tosses 
about in his bed, becomes extremely restless and markedly agi- 
tated. Often he carries on conversations with imaginary per- 
sons. His speech is incoherent and muttering and states of 
carphologia and subsultus tendinum are common. 
POST-INFECTIOUS PSYCHOSES 
Postfebrile Delirium.-The psychic phenomena continuing 
after the febrile state comprise conditions of disorientation, con- 
fusion, delirium, dreamlike states and epileptiform excitements. 
The patient often has auditory hallucinations, and delusions of 
persecution lend a color to the clinical picture. States of depres- 
sion and marked apprehension are common. 
Debilitation and prostration are the etiological factors in 
these conditions, and they bear a close resemblance to the deliria 
of exhaustion, but they are differentiated from the latter by their 
direct causal relationship to some preceding infectious disease. PSYCHOSES WITH SOMATIC DISEASES 
133 
To this group belong the chronic states of toxemia which have for 
their expression the non-alcoholic Korsakow's psychosis. 
EXHAUSTION DELIRIUM 
Definition and Etiology.-Mental symptoms may develop 
after severe exhaustion such as that which attends loss of blood, 
mental and physical shock, the puerperal state, deprivation of 
food, protracted insomnia, prolonged convalescence from tuber- 
culosis, pneumonia, influenza, typhoid fever and other infec- 
tious diseases. There are two main types of this disorder; col- 
lapse delirium and acute hallucinatory confusion. 
Pathology.-No definite pathology has been found, for rela- 
tively few cases have been examined. There have been observed, 
however, degenerative changes in the cerebral cortex and morpho- 
logical changes in the chromatin substance. 
Symptomatology.-Collapse Delirium.-The disease is ush- 
ered in by a prodromal period of anxiety, insomnia and restless- 
ness, succeeded by a condition of confusion and perplexity. This 
by degrees becomes intensified and the patient then exhibits de- 
lusions and hallucinations. Orientation becomes defective in 
all spheres. Great psychomotor excitement supervenes; the pa- 
tient is exceedingly active and may commit acts of violence. In 
the more severe cases the disorientation becomes complete. The 
patient is stuporous. The physical condition is characterized 
by anorexia, gastrointestinal disorders, profound prostration, 
diarrhoea, typhoid symptoms and emaciation, and frequently by 
coma. Albuminuria is a more or less constant symptom. 
Acute Hallucinatory Confusion.-This form of the exhaustion 
psychosis is not so marked as the collapse delirium. The symp- 
toms are essentially the same, but of much milder character. 
Various degrees of clouding of consciousness may exist. The pa- 
tient talks in an incoherent, irrelevant manner, seems to be in 
a daze, and has fleeting and ever changing hallucinations and de- 134 
MANUAL OF PSYCHIATRY 
lusions. The delirium may be of the occupational type. Oc- 
casionally there are brief periods in which consciousness is clear 
and the patient talks and behaves in a rational manner. This 
temporary remission in the psychosis leads to erroneous diag- 
nosis and gives rise to unfounded hopes for an early recovery. 
Occasionally the hallucinatory confusion is punctuated by stu- 
porous states. 
Diagnosis.-The history of an acute infectious disease, hem- 
orrhage, shock or similar condition, the confusion and change- 
able character of the delusions and hallucinations, disorienta- 
tion, and the general physical condition of the patient, simplify 
the diagnosis. It should be remembered that other mental dis- 
orders have their origin in infectious disease and that any psy- 
chosis may have, in addition to its characteristics, those symp- 
toms which attend an infection. Special care must be exercised 
to exclude delirium tremens, epilepsy and catatonia. 
Course and Prognosis.-The prognosis depends entirely upon 
the virulence of the infection, the severity of the exhaustion and 
the vitality and resistance of the patient. If a delirium starts 
early in the course of an infectious disease, the case is to be re- 
garded as a serious one. Where the exhaustion has been ex- 
treme the outlook is not favorable. An amelioration of the men- 
tal symptoms is generally associated with an improvement in the 
physical condition of the patient. Death is the termination of 
approximately 50 per cent of the exhaustion psychoses. 
Treatment.-The underlying physical disease must receive 
its appropriate treatment. The patient's strength must be sup- 
ported and maintained by sufficient amounts of liquid nourish- 
ment by mouth if the patient is able to swallow; otherwise by 
tube feeding if this can be done without danger to the patient. 
The method of administering nourishment by the rectum has 
been employed with satisfactory results. PSYCHOSES WITH SOMATIC DISEASES 
135 
CARDIO-RENAL DISEASE 
The most important of the symptoms which attend cardio- 
renal disease is the condition of uremia. 
Uremic Delirium.-The psychotic symptoms which attend 
uremia are of two varieties so far as their emotional character 
is concerned. They are of the depressed and the euphoric type. 
Both forms are characterized by disorders of consciousness rang- 
ing from a condition of slight haziness and confusion to pro- 
found clouding. Orientation may be disturbed to any degree in 
any sphere, corresponding to the degree to which consciousness 
is clouded. Hallucinations and delusions accompany both forms. 
The physical symptoms such as dyspnoea, edema of the ex- 
tremities and other portions of the body, low specific gravity 
of the urine, albuminuria, and the presence of casts, blood cells 
and pus in the urine, manifested in both types, are evidences of 
cardio-renal disease. Conditions of anuria, polyuria and oliguria 
may be encountered. The neurological symptoms are twitching 
of the body muscles, convulsions, and pupillary disorders such as 
irregularities, inequalities, pinpoint pupils and iridoplegia. As 
a rule all body movements are clumsy, inaccurate and ataxic. 
In the depressed form the patient may complain that his food 
and drink are being poisoned; that enemies are seeking his de- 
struction; that they are planning to destroy his home; that they 
charge him with electric currents and otherwise seek to injure 
him. This state of fear and delusion is often accompanied by 
great restlessness and agitation, making it difficult at times to 
restrain the patient. When this form is attended by stupor, 
states of catalepsy are occasionally noted. In the euphoric type 
the patient entertains expansive delusions of all sorts. He may 
believe that he is a great soldier, or statesman, or scholar, or 
some celebrity. He orders those who attend him to treat him in 
accord with the nature of his megalomanic delusions, orders great 
feasts, hires hundreds of servants, and gives commands of all 136 
MANUAL OF PSYCHIATRY 
sorts. Frequently he believes that Deity has appointed him to 
perform some great commission; that he has become an angel or 
other superhuman being. 
Diagnosis.-The history of the case, the general physical 
findings and the examination of the urine make the diagnosis 
fairly easy. Uremia has at times seemed to serve as an excit- 
ing factor in the production of delirium tremens, and the latter 
should be excluded in making the diagnosis. 
Prognosis.-The prognosis is always grave. 
Treatment.-The restlessness and convulsions should be con- 
trolled by hydrotherapy or the use of bromides, morphine and 
small doses of chloral if necessary. The bowels should be thor- 
oughly emptied and kept open, and the skin should be rendered 
active by the use of diaphoretics and hot loin packs. Blood let- 
ting is often of great value. The Murphy drip is of great bene- 
fit, and normal saline and glucose solution may be employed. 
Some cases call for intravenous injection of normal saline, 300 
to 500 c.c. to be given daily or every second day and the pa- 
tient to be watched for indications of overburdening the heart. 
If collapse obtains, strychnine, digitalis and camphorated oil 
should be given hypodermically. The diet should be liquid. 
Vegetable and fruit juices and milk are proper. During the 
period of convalescence the patient should spend much time in 
the open air in definitely arranged periods of moderate physical 
exercise, recreation and rest. 
DISEASE OF THE DUCTLESS GLANDS 
Diseases of the thyroid gland are attended by mental symp- 
toms more often than are diseases of the other ductless glands. 
The psychotic disturbances which attend disease of the thyroid 
gland are those due to hyperthyroidism and exophthalmic goitre, 
hypothyroidism (myxedema and cretinism) and conditions of PSYCHOSES WITH SOMATIC DISEASES 
137 
dysthyroidism, the symptoms of which are less clearly pro- 
nounced. 
Hyperthyroidism and Exophthalmic Goitre.--Psychotic 
conditions are noted in the vicious types of hyperthroidism fol- 
lowing surgical operations in which an excessive amount of the 
glandular secretion has been let loose in the circulation due to 
tearing of the capsule of the gland or to excessive handling dur- 
ing surgical procedure, or to the administration of thyroid gland 
substance in susceptible individuals. A patient suffering from 
exophthalmic goitre is usually very irritable, excitable and nerv- 
ous, lives in a mild state of mania, exhibits periods of depression 
and suspicion, suffers from insomnia and complains of violent 
headaches. A condition of chronic fear has been observed. De- 
lirium often develops which is attended by hallucinations of 
sight and hearing. The patient becomes restless, disturbed and 
noisy, picks at the bedclothes, talks incoherently and gesticulates. 
In marked cases the patient becomes exhausted by his restless- 
ness and maniacal excitement, and death frequently ensues as 
a result of thyroid intoxication. These symptoms of thyroigen- 
ous insanity make their appearance more frequently in persons 
who spring from a neuropathic stock. 
Hypothyroidism (Myxedema and Cretinism).-Myxe- 
dema.-Too radical operations for hyperthyroidism have resulted 
in conditions of myxedema, due to extensive removal of the 
gland itself or to a degenerative process in the stump of the 
gland that is left. The patient presents the usual features of 
myxedema: dryness of the skin, clublike fingers, increase of the 
fatty and connective tissues of the face, bradycardia, and lower- 
ing of the temperature. There is impairment of the mental pow- 
ers. The patient is dull of comprehension, with marked failure 
of attention and impairment of memory. All mental operations 
are slow and imperfect. Occasionally the patient exhibits 
episodes of excitement and anger and at times gives expression 138 
MANUAL OF PSYCHIATRY 
to delusions of persecution and feels that he is being discrimi- 
nated against. Unless the condition is improved by proper 
medication the disease ends in permanent dementia. Cases of 
incomplete myxedema are occasionally overlooked. 
Cretinism.-This condition of the thyroid gland, due to lack of 
development, is shown by the physical symptoms common to 
myxedema. The mental defect is one of profound feebleness 
ranging from a state of idiocy to one of imbecility. 
Dysfunction of the Thyroid Gland.-There are disturbances 
of the thyroid gland which do not fit the two general classifica- 
tions just described; in fact there may be a mixture of the symp- 
toms. We find in this group of cases alternate periods of ex- 
citement and depression and states of delusion and delirium. 
OTHER DISEASES OR CONDITIONS 
a. Diabetes.-States of depression varying from a mild to a 
profound degree are frequent among patients suffering from dia- 
betes. There is a general impairment of the patient's mental 
capacity. Preceding the state of depression he becomes dull, 
stupid, indifferent and apathetic. Often he feels that he has 
committed some grievous sin; that he has worked the destruction 
of his friends or family. He gives expression to ideas of self- 
destruction, becomes confused and talks in an incoherent manner. 
He pronounces his words indistinctly, becomes somnolent, and as 
the state of coma approaches he becomes disoriented. At such 
times there are delusions of persecution and occasionally episodes 
of marked excitement. Diabetic coma may appear at any stage 
of diabetes and is usually preceded by some of the symptoms just 
described, in addition to physical symptoms of marked weak- 
ness, headache, dizziness and insomnia. The skin becomes hot 
and dry and the amount of urine excreted is diminished. 
b. Gout.-Psychotic episodes rarely appear with gout, 
although they have occasionally been noted. The mental symp- PSYCHOSES WITH SOMATIC DISEASES 
139 
toms are those of delirium and confusion. These states are at- 
tended by transient hallucinations, especially those of sight and 
hearing. 
c. Gastrointestinal Disorders.-Violent infections of the 
gastrointestinal tract which produce great pain and marked 
diarrhoea, associated with albuminuria and indicanuria, high 
temperature and profound exhaustion, are attended by states of 
confusion, delirium and coma. Malignant disease of the liver, 
stomach, uterus, pancreas and intestines is often attended by 
states of depression, irritability and mild delusions of persecution. 
Patients who have insight into their condition frequently commit 
suicide. 
d. Pellagra.-Frequently pellagra is attended by mental and 
nervous symptoms. This disease has been found in the United 
States to quite a marked extent in the hospitals for the insane 
in the south and middle west, and particularly in the State of 
Illinois. In one class of cases the spinal cord alone seems to be 
involved; in others the brain. Occasionally types are met with 
in which the brain and spinal cord are equally involved. It has 
been noted that individuals suffering from such diseases as de- 
mentia prsecox, manic depressive insanity and senile psychosis 
are likely to develop pellagra or to have pellagra engrafted upon 
their original insanities. 
About seven types of symptoms have been noted. Some of 
the patients display only marked conditions of neurasthenia at- 
tended by states of depression. In other cases there are mental 
symptoms which may remain stationary or may progress until 
the patient becomes extremely retarded and noncommunicative 
except for the periods when he gives expression to delusions of 
persecution or complains of auditory and visual hallucinations. 
Conditions of confusion and delirium are frequently encountered, 
and these often deepen into stupor. States of marked anxiety, 
have been observed. Manic depressive reactions appear in some 140 
MANUAL OF PSYCHIATRY 
instances. Some cases resemble general paresis. The tendency 
to suicide by drowning is often exhibited. There has been an 
attempt to explain this on the theory that conditions of acro- 
paresthesia have caused patients to seek water for relief. 
Pathology.-The exact causative pathology of this disease is 
still a matter of uncertainty, but the following conditions have 
very frequently been found at autopsy in the American cases of 
pellagra. 
Gross Pathology 
Thickening of the meninges of the 
cord 
Formation of osseous plaques 
Posterolateral sclerosis, especially in 
the upper portions of the cord in 
the Columns of Goll and Burdach. 
Microscopic Pathology 
Atrophy of anterior horn cells 
Pigmentation of anterior horn cells. 
Treatment.-No specific treatment has yet been found, but a 
general improvement in the character of the foods taken, and 
tonic medication with arsenical preparations such as Fowler's 
solution and salvarsan, have been found of service. 
e. Rheumatic Fever.-When the temperature is high, rheu- 
matic fever may be attended by states of confusion and delirium. 
During these conditions the patient may exhibit hallucinations 
and delusions of a painful character. Convulsions have been 
noted, especially in those cases where there is hyperpyrexia. In 
fatal cases coma sometimes makes its appearance without the 
development of delirium or states of confusion. 
j. Malaria.-Malaria is infrequently attended by mental and 
nervous symptoms, but they have occasionally been observed. 
Peripheral neuritis, paraplegia, hemiplegia and aphasia are the 
prominent neurological symptoms. The chief mental symptoms 
are those of motor restlessness, confusion and delirium which 
sometimes progress to states of stupor. These symptoms may 
appear at the febrile stage or they may occur after the febrile 
phenomena of the disease have subsided and the proper specific PSYCHOSES WITH SOMATIC DISEASES 
141 
medication has been given. In these cases the mental symptoms 
may be chargeable to exhaustion and collapse. In the remittent 
types conditions of pyrexia or convulsive attacks of an epileptoid 
nature are observed. In patients who suffer chronically from 
malaria there may be a condition of hebetude. Dementia has 
been noted in countries where malaria is pandemic. The prog- 
nosis depends upon the success of the treatment for malaria and 
the integrity of the nervous system of the patient affected. 
g. Pregnancy, Parturition, Puerperium and Lactation.- 
These physiological epochs are often attended by psychotic 
states which seem to be directly related to the biological func- 
tions mentioned, but the relationship is such that it is still a 
question whether the terms puerperal insanity and lactational 
insanity are accurate. They indicate the time of appearance of 
psychotic symptoms rather than the causal relationship. The 
really important factors in the case of psychoses developed at 
this time are heredity, infection, exhaustion, and the powerful 
psychogenetic factors of shame, fright and grief which act in 
illegitimate pregnancies in special instances and produce pro- 
found depression. 
Pregnancy.-At any time during pregnancy there may grad- 
ually or suddenly occur a change in the mental status of the 
patient. She may become very much depressed, fearful and 
irritable. These symptoms seem to be proportionate to the in- 
tensity of the morning sickness and nausea. In some instances 
painful delusions develop, especially in those who are illegiti- 
mately pregnant. Delirium often occurs. At such times hal- 
lucinations of smell, taste and hearing are common. Suicidal 
tendencies are occasionally exhibited. Frequently the act of 
self-destruction is carried out. During the period of pregnancy 
symptoms of the essential insanities such as dementia praecox 
and manic depressive insanity make their appearance. 142 
MANUAL OF PSYCHIATRY 
Parturition.-Mental symptoms may not occur until the time 
of labor. Delirium is common, attended by painful hallucina- 
tions of smell, sight and hearing, and delusions of infidelity. 
Eclamptic convulsions occur at this time, due to disorders of 
metabolism. The changes which occur in the uterus and mam- 
mary glands are likely to surcharge the circulation with toxic 
substances. 
Puerperium.-Following the birth of the child there may be a 
marked change in the patient. She may become irritable, sus- 
picious and depressed and take a great dislike to her child. Often 
she will attempt to smother it with the bedclothes, to strangle it 
or throw it out of bed or otherwise injure it. She may display 
marked hatred for her husband. The patient becomes emaciated, 
the urine is diminished in quantity and the bowels are consti- 
pated. There is suppression of the milk and also of the lochia. 
This type of psychotic disturbance seldom occurs earlier than five 
days following the delivery, and usually about the time the 
patient leaves her bed. It occurs more frequently following the 
birth of the first child and in persons bearing children late in 
life. The symptoms exhibited may be those of a delirium 
simply, or they may be the expression of some one of the essen- 
tial psychosis such as dementia praecox, manic depressive in- 
sanity or paranoia. 
Lactation.-At any time during the period of lactation psy- 
chotic symptoms may be exhibited, but they usually occur about 
the third or fourth month following pregnancy. The patient 
becomes irritable and restless and has states of confusion which 
are attended by transitory delusions of a painful character. 
Sometimes there are delusions of infidelity. Probably the most 
potent factor in producing mental symptoms at this period is 
exhaustion. The patient is usually anemic and debilitated and 
suffers from insomnia, restlessness and loss of appetite. Unless 
some essential psychosis makes its appearance, the patient is PSYCHOSES WITH SOMATIC DISEASES 
143 
ordinarily restored to mental health in a few weeks under proper 
hygienic, dietetic and tonic treatment. 
h. Influenza.-Influenza is occasionally manifested in forms 
in which the nervous symptoms predominate. Meningitis and en- 
cephalitis occur and have as their sequelae monoplegia or hemi- 
plegia. In the milder types some forms of neuritis are often 
found. The mental symptoms are chiefly those of marked de- 
pression which may progress to states of melancholic stupor. 
Very frequently some of the essential types of insanity, such 
as dementia praecox or manic depressive insanity, follow in- 
fluenza. 
i. Lethargic Encephalitis.-Lethargic encephalitis is at- 
tended by a train of nervous and mental symptoms, chief of 
which are involvements of the various cranial nerves, disorders 
of the reflexes, states of confusion, delirium, lethargy and som- 
nolence. 
Etiology.-This disease first made its appearance in North 
America in the winter of 1918-1919, following the epidemic of 
the so-called Spanish influenza. Both sexes are equally affected. 
No organism has been definitely isolated as being the cause of 
this disease, but research concerning its origin warrants the be- 
lief that it is an infectious disease of an inflammatory nature, 
probably due to a filterable virus. Its exact relation to influenza 
has not yet been determined, however. The history of lethargic 
encephalitis shows that a majority of the cases have been pre- 
ceded by an attack of influenza. 
Gross Pathology.- 
1. Congestion of the cranial meninges. 
2. Hyperemia of the cortex. 
3. Hyperemia of the basal ganglia. 
4. Inflammatory condition about cerebral blood vessels. 
5. Punctate hemorrhages in the brain substance. 
6. Same condition found in the cord and its meninges. 144 
MANUAL OF PSYCHIATRY 
7. Edema of the lung. 
8. Hyperemia of the heart muscle. 
9. Congestion and engorgement of the kidneys, liver and 
spleen. 
Microscopic Pathology.- 
1. Distention of minute blood vessels of pia with blood cells. 
2. Round cell infiltration about blood vessel walls. 
3. Perivascular infiltration of the cerebrum, cerebellum, me- 
dulla, pons and basal ganglia of both the white and gray matter. 
The cells are mostly lymphocytes, plasma cells and mononuclear 
cells. 
4. Cloudy swelling of the heart, kidney, liver and spleen. 
5. Spinal fluid is usually clear. It may be under slight pres- 
sure. The globulin: Lange and mastic tests are usually nega- 
tive. The cell count is increased from 10 to 100 per cu. mm. 
Symptomatology.-The disease is usually ushered in by ma- 
laise, headache, gastro-intestinal pain, vomiting and constipation. 
The fever varies from slightly above normal to 104 or 105 de- 
grees F. Very soon twitching and jerking of the body muscles 
is noted. At this time any of the cranial nerves may become in- 
volved. Ptosis, diplopia, strabismus, nystagmus, dysphagia and 
facial paralysis have been observed. The face takes on a mask- 
like appearance; the lines of expression are effaced and the 
muscles become flaccid. There may be drooling of the saliva. 
The peripheral nerves show evidence of involvement by lancinat- 
ing pains in the occipital region, along the spinal column and in 
the upper and lower extremities. The chief mental symptoms are 
restlessness, motor agitation and marked irritability. Periods 
of delirium and stupor develop which are attended by fleeting 
hallucinations and delusions of a paranoid character. The stupor 
grows more profound until the patient sinks into a state of leth- 
argy or coma. In the cases not terminating in death, periods of 
lucidity punctuate the state of lethargy. PSYCHOSES WITH SOMATIC DISEASES 
145 
Treatment.-Isolation. Spinal drainage will relieve the head- 
ache caused by increased intracranial pressure due to exudation. 
Medical treatment is purely symptomatic. Great care must be 
exercised in the use of sedatives at the inception of the disease 
during the period of restlessness and excitment, lest the drug in- 
crease the stupor. If possible, hydrotherapeutic measures should 
be employed as a sedative. CHAPTER XIII 
MANIC-DEPRESSIVE PSYCHOSES 
Definition.-The manic-depressive psychoses are recurring 
mental disorders which are characterized by periods of depres- 
sion and excitement. These two phases may alternate, with or 
without a period of lucidity intervening, or the same phase of the 
disorder may be repeated, or recovery from an attack of one 
phase of the psychosis may occur. These psychoses belong to the 
benign type of the affective mental disturbances and are not 
attended by intellectual impairment except in those cases where 
the periods between attacks are very brief. In the course of these 
disorders hallucinations, delusions and illusions may be exhib- 
ited. The terms acute or chronic mania and acute or chronic 
melancholia were formerly applied to the two phases, and they 
were regarded as two distinct diseases. The psychoses are 
grouped into three types, according to the predominating char- 
acter of the symptoms: 
Depressive Forms 
Manic Forms 
Mixed Forms. 
Etiology.-From 15 to 25 per cent of all patients in hos- 
pitals for the insane suffer with some phase of these disorders. 
The manic-depressive constitution is often the heritage of cer- 
tain families. The statistics gathered in state hospitals for the 
insane indicate that heredity taint is found in the family 
history of about 75 per cent of all patients. It has been noted 
that this disease occurs in persons born prematurely, for such 
individuals are likely to possess obscure developmental defects 
146 MANIC-DEPRESSIVE PSYCHOSES 
147 
of the nervous system. The manic-depressive psychoses are 
more often found among female patients than among male. 
The first attack usually makes its appearance between the twen- 
tieth and thirtieth year, though it has been known to occur be- 
fore the age of twenty and as late as seventy years. Any of the 
following conditions acting upon a congenital or acquired neuro- 
pathic state may precipitate an attack of this disorder: 
1. Mental and physical shock. 
2. Painful neuralgias. 
3. Pregnancy. 
4. Parturition. 
5. Lactation. 
6. Influenza or other febrile disturbances. 
7. Gastro-intestinal disorders. 
8. Long-continued worry. 
The disease may suddenly manifest itself without any appar- 
ent exciting cause. 
Pathology.-No demonstrable pathology has been found. 
Interstitial nerve cell pigmentation of the cortex has occasionally 
been noted. 
Symptomatology.-Depressive Phase.-Three cardinal symp- 
toms stand out very clearly in this phase of the disease: 
First.-Slowness and difficulty of thinking. 
Second.-Psychomotor retardation. 
Third.-Emotional depression. 
The intensity and severity of these symptoms are not always 
uniform. The very slightest retardation of the mental processes 
may be attended by profound emotional depression. The reverse 
is often true. Occasionally the emotional depression is extremely 
great and the psychomotor activity is increased. The depressive 
phase may be of four degrees: 
First.-There may be very mild slowing of the mental process, 
attended by simple depression. 148 
MANUAL OF PSYCHIATRY 
Second.-In the second degree the retardation is more pro- 
nounced. 
Third.-The depression may increase until there is a state of 
well-defined melancholia. 
Simple Depression.-The depressive phase is usually ushered 
in by a prodromal period in which the patient suffers from ano- 
rexia, constipation, insomnia, headache and general bodily weak- 
ness. During this period the patient is simply depressed. 
Simple Retardation.-This is a state that is merely an accen- 
tuation of the condition just described. The patient suffers from 
feelings of sadness, vague fears, attacks of the blues, and tran- 
sient periods of irritability. He moves very slowly and talks in 
the same manner. His voice is scarcely audible. He prefers to 
answer yes or no to all questions. He takes little or no interest 
in his environment; seeks his own company. In this state the 
patient is fully oriented and consciousness is not clouded. He 
often has some insight into his condition; feels that something is 
wrong within himself. 
Acute Melancholia.-As the disorder progresses the patient 
passes into the third stage of acute melancholia. He becomes 
very much depressed and his mental condition is reflected in his 
bodily attitudes. He sits with his body bent forward, his chin 
resting upon his breast, or with his face supported by his hands, 
with the elbows resting on his knees. He appears very much dis- 
tressed and wears a painful and anxious expression. In the acute 
form the patient frequently becomes agitated. He paces the 
floor, wringing his hands and declaring that he has committed 
some unpardonable sin, or that he has caused humanity to suffer 
because of his conduct. Or he may declare that his blood is dried 
up; that his brain is petrified; that certain organs of his body 
are missing. Not infrequently there is exhibited a marked ten- 
dency to suicide. As a result of the painful delusions and mis- 
guided sympathy, the melancholiac has been known to murder MANIC-DEPRESSIVE PSYCHOSES 
149 
his children to save them from starvation, poisoning, rape, or 
other fancied danger. As a rule consciousness remains fairly 
clear and marked disorders of orientation are rare. The patients 
think exceedingly slowly. Sensation is impaired and external 
stimulation is met with delayed response. They experience great 
effort and a sense of discomfort in applying themselves to even 
a slight task. The simplest acts are painfully and clumsily per- 
formed. Memory is usually accurate, but organic memory may 
be impaired as a result of the delusions affecting personality. 
The patients pay very little attention to their environment. Vol- 
untary attention is much disordered. For example, a book may 
be placed in the patient's lap. When he discovers it he may feel 
that it came into his possession by some mysterious agency, be- 
cause he failed to perceive that someone placed the book there. 
Stuporous Melancholia.-If the disease progresses beyond the 
third stage the patient may pass into a state of stuporous melan- 
cholia. In this condition consciousness seems to be clouded; 
hallucinations and delusions occasionally appear, because of the 
patient's lack of attention and failure of perception. The wants 
of nature are neglected, the patient refuses his food, and tube 
feeding becomes necessary. The physical symptoms of the pro- 
dromal period increase with the progress of the disease. The 
patient loses in weight, suffers from constipation or diarrhoea, 
and the extremities of the body are blue and cold, due to defec- 
tive circulation. The urine is usually loaded with indican and 
urea. The temperature may be subnormal. The pupils are usu- 
ally widely dilated and the conjunctiva are anemic. Headaches 
are common. 
Manic Phase.-There is an outstanding triad of symptoms in 
the manic phase which is practically the reverse of the symptoms 
of the depressive phase. These distinctive symptoms are flight 
of ideas, increased psychomotor activity and emotional excite- 
ment. These characteristic symptoms may show the same va- 150 
MANUAL OF PSYCHIATRY 
nations of intensity as in the depressive phase. The maniacal 
type of the manic form may be exhibited in one or all of the fol- 
lowing degrees: 
First.-A period of restlessness. 
Second.-A condition of hypomania. 
Third.-Acute mania. 
Fourth.-Hyperacute or exhaustive mania. 
Period of Restlessness.-At the onset of this period the for- 
merly depressed and lethargic individual shows an increase in 
mental and motor activity a few degrees above the normal; he 
becomes a busybody. 
Hypomania.-The symptoms of the preceding stage rapidly 
increase and a condition of hypomania obtains. Hyperactivity 
is shown in the mental and physical fields. The patient under- 
takes a multiplicity of projects, many of which are diametrically 
opposed to one another, and he expresses great anger if any 
one of his plans is temporarily delayed. His impatience is so 
great that he is unable to transact his business by common sense 
methods. He sends telegrams and special messages when the 
facilities of the ordinary mail would suffice. He writes in- 
numerable letters. Ideation is extremely rapid but interrupted 
and reversed. The patient is talkative and egotistical. He in- 
dulges in witticisms; laughs hugely at his own jokes. Excessive 
indulgence in wine, and debauchery with lewd women, are com- 
mon. Prodigal and reckless financial operations are frequent 
occurrences. Consciousness remains clear and orientation is not 
disturbed. The memory may be keen for recent and remote 
events. Aside from the state of extreme unproductive activity, 
few psychotic symptoms are manifested. The patient's ideas 
and separate acts are not in themselves departures from the 
normal, but the sum total of all his mental activities and con- 
duct is distinctly so. There is a pressure of ideas, so to speak. 
All ideas are seeking for the mastery in expression, but the MANIC-DEPRESSIVE PSYCHOSES 
151 
change is so rapid that while a great amount of mental and phys- 
ical energy is expended, nothing worth while is accomplished. 
Acute Mania.-The patient now presents the following symp- 
toms: There is a rapid flow of ideas. Conversation is quite in- 
coherent and irrelevant. Distractibility is very evident. There 
is a marked tendency to the senseless rhyming of words. This 
symptom is called klang association. Hallucinations and illu- 
sions of a transient character may be exhibited, and delusions 
of a grandiose nature are frequent. Often the patient declares 
that he has been called upon by Deity to perform some great 
mission. He is emotionally exalted and given to egotistical ex- 
pressions about his personal attainments. At other times he 
may be extremely irritable and annoying trifles are sufficient to 
produce outbreaks of temper. Patients of this class are exceed- 
ingly restless and constantly keep in motion. Often the cloth- 
ing is destroyed, furniture is demolished, window lights are 
broken, and a constant confusion of talking and yelling is kept 
up for hours at a time. All manner of clownish gymnastics, danc- 
ing, running and gesticulating, are carried on for long periods 
without apparent muscular fatigue. Insomnia is a more or less 
constant symptom. Owing to the pressure of activity the pa- 
tient takes but little food and drink, and as a result there is 
marked emaciation and exhaustion if the paroxysm of psycho- 
motor activity is of sufficient duration, and the patient becomes 
weakened. In this debilitated condition consciousness is usually 
somewhat clouded and personal orientation impaired or lost. 
The patient frequently mistakes the identity of those about 
him; calls his nurse and his physician by the names of members 
of his family. The calls of nature are ignored and the personal 
appearance is sadly neglected. Physically the patient suffers 
from anorexia, the tongue is dry and coated and the bowels are 
alternately constipated or exceedingly loose. The urine is usu- 
ally scanty but sometimes greatly increased in solid content 152 
MANUAL OF PSYCHIATRY 
and amount. The circulation is rapid and the skin as a rule is 
hot and dry. The temperature is occasionally elevated. 
Hyperacute or Exhaustive Mania.-The symptoms may now 
subside or the condition gradually merge into a state of hyper- 
acute or exhaustive mania. The symptoms of this condition bear 
a close resemblance to those of an acute inflammatory disease 
of the brain or meninges. Consciousness is clouded to a marked 
degree. Extreme restlessness and senseless activity are present. 
Disorientation is complete. Insomnia of the most obstinate form 
develops. The excitement takes on the character of a delirium; 
the patient mutters to himself, picks at the bed clothing, scratches 
and mutilates his body and pulls out his hair. The scratches 
which the patient sustains become infected, and because of his 
great restlessness they cannot be given the proper surgical at- 
tention. The temperature becomes elevated as the result of 
autointoxication and pus infection. If the state of hyperacute 
mania continues for any length of time, death generally ensues. 
Manic states associated with constitutional disorders such as 
nephritis, diabetes or pneumonia are practically always fatal. 
Mixed types of the manic depressive psychosis are often noted. 
The following mixed types are the most prominent. 
Depressive Mania.-This is a condition of agitated depres- 
sion. The patient keeps in constant motion, weeps and wrings 
the hands. The thinking processes are greatly retarded. 
Depressive Mania with Flight of Ideas.-In this condition the 
psychomotor activity is decreased. The patient talks constantly. 
Stuporous Mania.-There is exaltation of the emotions, re- 
tardation of the thinking processes, and slowness of movement. 
Unproductive Mania.-There is a state of euphoria. Physical 
movements are increased; thinking processes are retarded. 
Recurrent Mania.-Repeated maniacal attacks separated by 
short lucid intervals. MANIC-DEPRESSIVE PSYCHOSES 
153 
Recurrent Melancholia.-Repeated depressive attacks sep- 
arated by short lucid intervals. 
Alternating Insanity.-The manic phase is followed by the de- 
pressive phase without a lucid period intervening. This type 
often assumes a double or mixed form. 
Diagnosis.-Dementia prsecox is to be distinguished from the 
manic-depressive psychoses by the underlying, basic dementia 
of the former. The stupor of catatonia is attended by mutism, 
negativism, muscular rigidity, dermatographia, and evidences 
of mental enfeeblement, and is without signs of mental suffering. 
Involutional melancholia occurs at the transitional period of 
life-fifty to sixty years-the physical and mental signs of in- 
cipient senility are present, and there is no alternate tendency 
to depression or elation. The psychic pain is pronounced in in- 
volutional melancholia. 
The depressive states of general paresis are superficial and 
the melancholy delusions are usually absurd and preposterous. 
The nervous symptoms of general paresis are absent in the 
manic-depressive psychoses. Usually the blood serum and spinal 
fluid Wassermann are positive in paresis. 
The diagnosis of manic-depressive psychosis is to be made 
on the strength of a history of repeated attacks of depression 
or elation, or both, the age of the patient, and the very slight 
tendency to mental deterioration. 
Psychology.-In both phases of this disease we have a weak- 
ening of the attention, a reduction of the altruistic emotions, a 
slowing of the ideational processes and an inhibition of voluntary 
action. In the depressive phases there is marked disturbance 
of attention due to conflict of perceptive values. The emotions 
are lowered by psychic pain and apprehension. The think- 
ing processes are slowed and painful fixed ideas are present. 
There is general reduction in psychomotor activity; activity is 154 
MANUAL OF PSYCHIATRY 
attended by a feeling of exhaustion and effort. In the manic 
phases of this disorder distractibility is pronounced. The emo- 
tional tone is raised; euphoria exists in varying degrees. Idea- 
tion is impaired by flight of ideas and there is no goal idea at- 
tained. Psychomotor activity is increased and activity is not 
attended by a sense of fatigue. 
Course and Prognosis.-Recovery from the individual at- 
tacks is common, but relapses are to be expected. The disorder 
may last from a few weeks to several months or even years. 
The change from one phase to another may be abrupt or de- 
velop gradually, with or without a lucid interval. One attack 
predisposes to another, and permanent recovery is not to be ex- 
pected. As the patient approaches the senile period the intervals 
of lucidity between attacks become less and the tendency to 
mental enfeeblement increases. 
Treatment.-Prophylactic.-During the interval between 
attacks the patient should lead a quiet, regular life devoid of 
all excesses. He should be engaged in some occupation which 
will meet the needs of his specific station in life, but it should 
not load the patient down with heavy responsibilities or worry. 
It is claimed by some psychiatrists that attacks of this dis- 
order may be prevented or arrested by the heroic use of seda- 
tives at the time of onset, in conjunction with very free catharsis 
and hydrotherapy. 
Depressive Phase.-Once the attack has established itself the 
patient should receive care in an institution, where he may be 
kept under constant supervision by trained attendants. The 
possibility of suicide must always be borne in mind. 
Hydrotherapy is of value in the agitated forms of the de- 
pressed phase, to allay excitement and restlessness and to over- 
come insomnia, which is so often a troublesome symptom. In 
the quiet depressed cases hydrotherapy is likewise indicated to 
keep up a healthy state of nutrition by equalizing the circula- MANIC-DEPRESSIVE PSYCHOSES 
155 
tion and increasing the skin elimination. Hydrotherapy may 
be employed in the form of warm and hot packs, prolonged tub 
baths and Scotch douches, according to the needs of the patient. 
In extreme cases of agitation small doses of hyoscine or even 
morphine may be used in connection with the hydrotherapy. 
The bromides, veronal, sulphonal, trianol and other sedative 
drugs may be used to overcome persistent insomnia. These are 
to be given along with hot milk at bedtime. The bowels should 
be kept active by the use of mild cathartics and laxatives. Ton- 
ics are to be employed in debilitated cases. 
The diet should be light but nutritious. Frequently the pa- 
tient refuses food and tube feeding must be resorted to in such 
cases. The method of tube feeding is described in the chapter 
on treatment. 
Manic Phase.-The same general rules of treatment are to be 
followed in this phase. Proper restraint and supervision in an 
institution are necessary. The excitement is to be controlled 
by hydrotherapy and the use of mild sedative drugs if this is 
imperative. Tonic medication is to be used in cases where it is 
indicated. Proper attention is to be given to the diet, that the 
general nutrition may not suffer. Tube feeding is to be re- 
sorted to in cases where the patient persistently neglects or re- 
fuses to take food. When the stage of convalescence is reached 
the patient should be given some form of occupational therapy 
according to his needs. This statement applies to both phases 
of the psychosis. CHAPTER XIV 
INVOLUTIONAL MELANCHOLIA 
Definition.-This psychosis makes its appearance at the cli- 
macteric, usually between the ages of forty and fifty in women, 
and fifty and sixty in men. As the name implies, melancholia 
and various degrees of depression are the predominating symp- 
toms. 
The psychic pain in this disorder is intense and interferes 
with the rational control of the intellectual processes. While 
it is true that this disorder belongs to the manic-depressive group 
of psychoses, its symptomatology is so well defined and char- 
acteristic that it has assumed a separate classification in psy- 
chiatric nomenclature. There are three main divisions, accord- 
ing to the type of symptoms exhibited. These are as follows: 
Self-Accusatory Type 
Anxiety or Pre-senile Type 
Apathetic Type. 
Etiology.-Changes in the arterial system, disturbances of 
metabolism and disorders of the endocrine glands are impor- 
tant factors. During the period of the menopause and the equiva- 
lent state in men, changes occur in the generative organs. The 
mind at this particular epoch of life is extremely susceptible 
to worries and emotional shocks, such as those which attend 
great grief or excitement. Great numbers of these psychoses 
developed in the war-ridden countries during the late conflict. 
These disorders are more likely to develop in persons of neuro- 
pathic constitution; heredity is a factor in about 60 per cent 
of all cases. 
156 157 
INVOLUTIONAL MELANCHOLIA 
Pathology 
Gross Pathology 
Degenerative changes in the heart 
muscle and bloodvessels, due to ar- 
teriosclerosis 
Degenerative changes of the kidney 
due to arteriosclerosis. 
Microscopic Pathology 
Degenerative changes in the cells of 
the cortex 
An increase in the neuroglia in 
the deeper layers of the cortex 
Degenerative changes in the cells 
of the motor tracts. 
Symptomatology.-The disease is ushered in rather slowly 
by a period of general malaise, a train of neurasthenic symp- 
toms such as dizziness, headaches, vague pains throughout the 
body, states of irritability, loss of appetite, insomnia, forget- 
fulness and loss of capacity to do mental work and to take in- 
terest in the environments. As the changes in the arterial sys- 
tem, the generative organs and the endocrine glands progress, 
the symptoms grow worse. 
Physical Symptoms.-The three forms of involutional mel- 
ancholia are attended by a train of physical symptoms, some of 
which have been described above. The patient has a feeling of 
discomfort and exhaustion. There is general diminution of the 
muscular powers; slight physical activity is attended by marked 
fatigue. The patient loses his desire for food, the breath be- 
comes foul and the bowels are, as a rule, constipated, though 
occasionally there are attacks of diarrhoea. The circulatory 
system shows evidences of deterioration. Occasionally there is 
precordial pain. Cyanosis of the extremities is frequent; the 
feet are cold; they feel numb to the patient. The hands may 
share in this condition, and often they are covered with a pro- 
fuse, clammy perspiration, while the skin of the rest of the body 
is harsh and dry. The pulse is, as a rule, irregular, thready and 
feeble; the temperature is sub-normal. 
The pupillary reflexes are sluggish and the tendon reflexes 
altered; usually diminished. The skin reflexes are diminished 
or absent. The whole picture indicates a general physical de- 158 
MANUAL OF PSYCHIATRY 
cline and beginning senility. Insomnia is a troublesome symp- 
tom, and the little sleep that is secured is fitful and disturbed 
by distressing dreams. 
Self-Accusatory Type.-In this form, the patient entertains 
delusions of self-accusation. He feels that he has committed 
some grievous sin; thinks that his soul is lost. Some indiscretion 
or sin of his childhood or youth is remembered, and about this 
particular offense he may weave a delusional conception that he 
has sinned against Deity or against organized religion. The 
patient may believe himself to be unworthy of any comfort or 
of food, and often refuses food and proper clothing on this ac- 
count. He goes about his room moaning and groaning, giving 
expression to his self-accusatory beliefs. Frequently the pa- 
tient is very restless and keeps in a constant state of agitation. 
Often he paces the floor, repeating, "My God, my God!" Sui- 
cide is a frequent termination of this type of melancholia. 
Consciousness is not clouded, as a rule, and the patient is 
usually oriented as to time, place and person. He complains 
of great pain in the chest, sharp, shooting pains about the heart, 
and difficulty in breathing. These symptoms increase and di- 
minish with the profundity of the depression. 
Anxiety of Pre-senile Type.-In this form the patients do not 
accuse themselves of sinful acts, but they display profound fear 
for the future. They are afraid that great catastrophes will oc- 
cur; that there will be earthquakes and floods; that their prop- 
erty will be taken away from them; that they will starve to death 
because of a famine that is impending. Every circumstance in life 
takes on a fearful and evil character; there is a feeling of being 
overwhelmed and crushed. This type of involutional melan- 
cholia occurs a little later than the form described above. Stereo- 
typed movements are common. They are usually rhythmical, 
and indicate, as a rule, the mental anguish suffered by the pa- INVOLUTIONAL MELANCHOLIA 
159 
tient. The symptoms progress with the decrease of the physi- 
cal powers. 
Apathetic Type.-As the name of this form implies, the pa- 
tient is extremely apathetic. He ceases to take an interest in 
life; he quits the struggle for existence; no longer tries to adapt 
himself to his environment; takes no interest in affairs going 
on about him; becomes very seclusive; neglects his former oc- 
cupation; pays but little attention to his personal appearance. 
He suffers from a depression, but it is not so profound as in the 
ether types. The symptoms of this form are largely of a nega- 
tive character. 
The delusions of involutional melancholia have been classi- 
fied by Weygandt according to their content, as 
Hypochondriacal Delusions 
Delusions of Sinfulness 
Delusions of Persecution 
Delusions of Poverty 
Ideas of Unworthiness 
Delusions of Explanation 
Ideas of Insignificance 
Nihilistic Ideas 
Delusions of Possession 
Ideas of Grandeur. 
Diagnosis.-The age of the patient, the beginning of senile 
decay, the neurological findings and the Wassermann reactions 
of the blood and spinal fluid make it easy to rule out general 
paresis. 
The intense mental anguish, the constant state of depression 
and the absence of alternating states of elation and depres- 
sion rule out manic-depressive insanity. Involutional melan- 
cholia bears a close resemblance to arteriosclerotic dementia 160 
MANUAL OF PSYCHIATRY 
and senile insanity. In fact it is considered by many psychi- 
atrists to be a connecting link between these disorders. 
Psychology.-Perception is not impaired to a marked extent 
except in the intense types. Consciousness remains clear as a 
rule. Hallucinations and delusions occur with great frequency. 
Orientation is not affected except in stuporous and marked de- 
lusional forms. Memory usually shows some slight impairment, 
especially for recent events. Judgment is impaired. The de- 
lusions usually fit the state of depression existing. The instincts 
are disordered. Great fear and self-subjection are the out- 
standing symptoms. The mental capacities are below par. It 
is no longer possible for the patient to meet his problems and 
repressed fears as he did in a state of mental health. He feels 
that he has has failed in making adequate adjustment to his en- 
vironment, and the failure is manifested by his depression and 
abnormal fears. 
Course and Prognosis.-Thirty to 40 per cent of patients 
suffering from involutional melancholia recover; the remaining 
60 or 70 per cent die from intercurrent disease, exhaustion or 
suicide. Suicide occurs more frequently in involutional melan- 
cholia than in any other form of mental disease. In the 
manic-depressive psychosis, depressive phase, suicide is not 
so likely, owing to the fact that there is great psychomotor 
retardation which interferes with the performance of any definite 
act. The flight of ideas of the manic phase, which prevents the 
reaching of a goal idea, likewise prevents self-destruction in the 
manic-depressive psychosis. 
The chances for recovery are in proportion to the ability of 
the patient to improve physically and gain weight. The pres- 
ence of absurd or grandiose ideas is an unfavorable symptom. 
Treatment.-The patient suffering from this disorder should 
be placed in an institution where he may receive the necessary 
supervision by trained attendants, for these patients are al- INVOLUTIONAL MELANCHOLIA 
161 
ways potential suicides. The patient's general health and 
strength are to be maintained by a light, nutritious diet, which 
should be frequently varied. Tube feeding must be resorted to 
in cases where the patient persistently refuses to take food. 
The bowels should be kept active by the use of appropriate ca- 
thartics and occasional enemas. Rest in bed is often sufficient 
to allay restlessness and agitation and serves to prevent loss of 
strength. 
When rest fails to bring about the desired result, hydrotherapy 
is to be employed in the form of warm packs and prolonged baths 
at body temperature. Mild sedatives may be employed, along 
w'ith hydrotherapeutic measures, to allay insomnia. Hot drinks 
may be given an hour before bedtime. If these do not suffice, 
small doses of veronal, trianol or sulphonal may be used. These 
drugs are to be given about an hour before bedtime, in hot milk. 
Tonic medication is to be used to stimulate the appetite and to 
improve the general nutrition of the patient. When the psychic 
pain is intense, tincture of opium may be given in doses of fifteen 
to sixty drops daily, but great care should be exercised to prevent 
habit formation. Valerian has proved of service in the author's 
practice to allay the emotional distress of the patient. CHAPTER XV 
DEMENTIA OR SCHIZOPHRENIA 
Definition.-Dementia praecox and schizophrenia are terms 
applied to a type of chronic psychoses which have their inception 
during the adolescent period of life. They are characterized by 
a more or less gradual process of mental deterioration and often 
end in a state of terminal dementia. This type of disease is 
punctuated by psychotic episodes and occasionally by remis- 
sions of variable duration. It occurs in five forms. These are 
as follows: 
1. Simple Type. 
2. Hebephrenic Type. 
3. Catatonic Type. 
4. Paranoid Type. 
5. Mixed Type. 
Etiology.-The statistics of hospitals for the insane indicate 
very clearly that at least 75 per cent of all dementia praecox 
patients are the offspring of psychopathic or neuropathic stock. 
It has been noted that this disease seems to be directly inherited 
in certain families. Dissimilar heredity is also frequently en- 
countered. Children born of parents who at the time of con- 
ception suffered from epilepsy, neurasthenia, alcoholism or tuber- 
culosis, or from some form of the essential insanities, seem 
to be predisposed to this disease. Approximately 25 per cent of 
all patients in hospitals for the insane belong to the dementia 
praecox group. Both sexes are affected to about the same degree. 
Sixty per cent of the cases develop before the twenty-fifth 
year. The catatonic and paranoid forms occur with greater 
162 DEMENTIA PILECOX OR SCHIZOPHRENIA 
163 
frequency in women than in men. About 75 per cent of the 
patients suffering from the hebephrenic type are men. 
The physical and physiological stigmata are very common 
among dementia praecox patients. We find malformations of the 
skull, irregularities of the features, ears without lobes, and high 
and narrow palates. Inferior and superior prognathism is com- 
mon. The histories of these patients show that they have been 
susceptible to alcohol; that they have been devoid of the natural 
filial instincts and normal affections. In many cases before the 
disease developed there was a blunting of the normal sexual im- 
pulse or a precocious sexual activity. 
Aside from the influence of heredity the following have served 
as exciting or precipitating factors: 
Psychic Factors 
Stress of any sort 
Mental shock 
Excessive emotion long continued 
Sudden fright 
Psychic trauma due to sexual ex- 
periences, seduction and desertion 
Buried painful complexes. 
Physical Factors 
Physical changes due to puberty 
Physical shock 
Hemorrhage 
Infectious diseases 
Pregnancy 
Childbirth 
Masturbation1 
Head injuries 
Dysfunction of the endocrine glands 
Dysfunction of the internal secre- 
tion of the testicle and ovary. 
Pathology.-The exact causative pathology is still undeter- 
mined. The following pathological changes have been found at 
autopsy: 
Degenerative changes in the cortical cells. 
Sclerotic patches in the frontal lobes. 
Obliteration of the capillaries in the cortex. 
Some areas of gliosis. 
An increase of neuroglia. 
Enlargement of the thyroid gland. 
1 More often a symptom. 164 
MANUAL OF PSYCHIATRY 
Atrophy of the thyroid gland. 
Pathological changes in the other endocrine glands. 
Imperfect development of the genital organs. 
Pulmonary tuberculosis is very frequently associated with this 
.disease. 
Symptomatology.-Mental Symptoms.-This group of psy- 
choses, as the name implies, has for its underlying foundation a 
gradual and insidious process of mental deterioration, which is 
likewise attended by a marked impairment of the emotions. 
Upon this basis there develop certain psychotic symptoms. In 
all its forms the characteristic evidences of this dementia are 
frequent. There is a condition of mental ataxia or a failure of 
coordination between the intellectual, emotional and volitional 
qualities of the mind. To this condition of mental incoordina- 
tion the term of intrapsychic ataxia has been applied. Some 
authors have insisted that there is a splitting up of the person- 
ality, and because of this they have used the term schizophrenia 
to describe the psychosis. The general mental symptoms of de- 
mentia praecox are mental apathy, various memory defects, in- 
difference to environment, emotional poverty, failure of the power 
to grasp new ideas, failure of voluntary attention, general super- 
ficiality of thought* incoherent and irrelevant conversation and 
bizarre and grotesque delusions. These symptoms will be later 
described in greater detail. 
Physical Symptoms.-At the onset of the disease or at some 
time during its course, fainting spells frequently occur. Some- 
times these attacks take on an epileptiform character. Again 
they resemble hysterical paroxysms and occur about twice as 
frequently in female patients as in male. The patients are given 
to grimacing, wrinkling the face and the brows, distorting the 
mouth and other features, and assuming grotesque and repulsive 
attitudes. They suck their tongues and lips, make guttural 
noises, sniff at the air, etc. DEMENTIA PJLECOX OR SCHIZOPHRENIA 
165 
The pupils are very often widely dilated and occasionally are 
found to be unequal. The tendon reflexes are usually active, 
although occasionally there is a reduction in this group of re- 
flexes. Often patients seem to be insensible to pain, but this in- 
sensibility may be more apparent than real. Irregularity of the 
pulse and tachycardia are frequently observed. Vasomotor 
changes are constant. The extremities are often very cyanotic. 
As a rule, dermatographia is found. The perspiration is usually 
increased and of a very foul odor. The body temperature is gen- 
erally slightly subnormal. The menstruation is very often dis- 
turbed; many times it ceases altogether. The flow of saliva is 
increased and in the demented state drooling at the mouth is a 
very common symptom. Patients are many times anemic and 
pale. Conditions of chlorosis have been very frequently ob- 
served. At the onset of the disease there is commonly a reduc- 
tion in body weight owing to anorexia and the influence of delu- 
sional beliefs. As the disease progresses the appetite increases 
and the patients may become gluttonous and take on excessive 
weight. 
Simple Type.-This form usually has a slow, insidious onset. 
The patient's mental characteristics gradually change. He 
ceases to be interested in his usual occupation; prefers to be by 
himself; gradually develops a state of apathy; neglects his usual 
duties; fails in his school work; finds it difficult to absorb new 
ideas. He indulges in eccentricities, ignores the usual and com- 
mon courtesies of life, is abrupt in his manner and lacking in 
feeling. These conditions are frequently attended by hysterical 
paroxysms or by mild states of depression. Periods of irrita- 
bility develop. 
The patient complains that other persons are imposing upon 
him; that they are seeking to interfere with his rest. He be- 
comes very restless. At this stage insomnia is frequent. The 
patient complains that he is all tired out; that he is in a fog or MANUAL OF PSYCHIATRY 
166 
lethargy. These feelings of mental hebetude he is unable to 
shake off. As the condition progresses the patient is unable to 
continue school work or carry on an occupation. Delusions and 
hallucinations may occur, and these are often of a paranoid 
nature. The patient imagines that he hears voices calling him 
names or saying disagreeable things to him. These false beliefs 
are usually only transient. Often patients suffering from this 
type of dementia praecox tramp from place to place and live 
the life of a hobo. To satisfy their feelings of unrest they fre- 
quently enlist in the military service. Under the regime of mili- 
tary life they soon break down. The late war has brought to 
light many cases. 
This form of the disease is chronic and recoveries are infre- 
quent, though it does happen that this type of dementia prsecox 
is sometimes aborted and in this aborted class are to be found 
many anti-social individuals of the hobo, prostitute and mild 
criminal types. 
Hebephrenic Type.-This type of dementia praecox forms 
about 60 per cent of all cases. It is usually sudden in its 
onset, although it may be preceded by a prodromal period of 
general lassitude, mental apathy, insomnia, anorexia and con- 
stipation. Succeeding this stage of invasion there follows a gen- 
eral depression of spirits, restlessness, mental confusion and in- 
coherence of speech. Delusions and hallucinations of a disagree- 
able nature now develop. The patient hears voices calling him 
obscene names. They accuse him of sexual crimes or tell him 
that he is a victim of masturbation. The delusions are many 
times of a depressive and self-accusatory nature. He becomes 
cynical; feels that persons about him are plotting to destroy his 
life; that they put poison in his food and drink. Often he be- 
lieves that he has committed the unpardonable sin; that he has 
murdered a relative or committed some other outrageous crime. 
These false beliefs not infrequently lead to suicide. DEMENTIA PILECOX OR SCHIZOPHRENIA 
167 
As the fundamental state of dementia increases the delusions 
and hallucinations may rapidly change in character and their 
content become exceedingly foolish and absurd. One of the 
writer's patients believed that there were three men in his head 
who were continually quarreling and fighting. Frequently pa- 
tients feel that their blood is dried up; that their legs are gone. 
Often the dementia prsecox patient claims that he is the Son of 
God; that he is the Holy Ghost or the ruler of the universe. He 
offers no arguments to support his delusions. The absurd be- 
liefs are merely stated by the patient to be facts. 
Patients of the hebephrenic type usually show a marked de- 
gree of emotional deterioration. Those circumstances, which in 
a normal individual would arouse a marked reaction, exert but 
little influence on their emotions or conduct. They receive the 
news of the death of the closest friend or relative with little emo- 
tion or absolute indifference and careless unconcern. If they 
were suddenly informed that they had inherited a large fortune 
they would likewise make no response and show no interest. 
As the active mental life grows less, the symptoms of 
chronic dementia supervene. The patient now talks to himself; 
he assumes unusual bodily attitudes, having a special predilec- 
tion for those which are most uncomfortable. He will sit in the 
hot sun all day rather than exert himself to move into the shade. 
He answers the simplest questions incoherently and seeks to 
evade all mental effort, usually replying "I don't know," to 
every inquiry put to him. He displays no interest in his environ- 
ment. Mental lethargy and vacuity are expressed in every atti- 
tude. The patient is careless of his dress; spills food on his 
clothing; often commits acts of public indecency without appar- 
ent shame. The conventionalities of society are disregarded and 
cast aside as meaningless. 
The mental deterioration progresses until the patient's life is 
merely a vegetative process. He mumbles to himself in an inco- MANUAL OF PSYCHIATRY 
168 
herent and unintelligible manner, makes silly grimaces and per- 
forms senseless acts. The wants of nature are neglected and no 
doubt some of the symptoms of general physical decline which 
attend this disease depend somewhat on the toxemia due to the 
absorption of poisonous matters from retained urine and feces. 
Echolalia, or the repetition of senseless words and phrases, is 
observed in this form. Echopraxia is likewise noted. The pa- 
tient repeats certain stereotyped movements for hours at a time. 
Verbigeration is often noted. The patient repeats a group of 
words or phrases or sentences continually. Again he will fill 
whole tablets with stereotyped phrases. 
The course of hebephrenia is uncertain. Active treatment at 
the time the disease is ushered in sometimes results in slight im- 
provement. As a rule, however, about 75 per cent of these 
cases go on to a state of terminal dementia. About 20 per 
cent of the cases show a mild degree of deterioration such as 
evidence of defective memory, impaired reasoning power, childish 
judgments, and inability to acquire new ideas. Attending this 
condition in this group of cases may be hallucinations and delu- 
sions that are more or less repressed and do not materially regu- 
late the patient's conduct. About 5 per cent of the cases of 
this type make what we may call "social recoveries." The keen 
edge of their mentality is worn off, but they are enabled to en- 
gage in manual pursuits such as gardening, farming, shoemak- 
ing, and activities of this sort. 
Catatonic Type.-This type of dementia praecox forms over 
18 to 20 per cent of all cases of schizophrenia. It usually 
has a gradual onset, but occasionally it may appear suddenly. 
This is sometimes the case when it is preceded by great physical 
or mental shock. The incipient state of catatonia is usually 
marked by a condition of mental depression and apathy. 
Hysteroid convulsions are not uncommon at this time. As the 
disease progresses the cardinal symptoms of this psychosis ap- DEMENTIA PRJECOX OR SCHIZOPHRENIA 
169 
pear. The patient now passes into an apparent apathy or state 
of stupor. The muscles are tense and rigid and he resists every 
effort made to move his limbs or body. Apparently no atten- 
tion is paid to anything in his environment. He will not answer 
the simplest questions. This form of negativism has been 
termed mutism. In some patients the muscular tension and 
negativism are replaced by a condition of extreme muscular flex- 
ibility and a condition highly susceptible to suggestion. The 
patient does what he is told, and often imitates in a senseless 
manner the gestures and actions of those about him. His limbs 
may be placed in various positions, and there they will remain 
until muscular fatigue affects them. To this state the term 
"flexibilities cerea" (waxen flexibility) has been applied. Re- 
acting to this marked degree of susceptibility, the patient re- 
peats, over and over again, words and phrases he hears (echola- 
lia), or he may repeatedly imitate movements of others made 
in his presence (echopraxia). 
The condition of catatonic stupor is irregularly alternated by 
periods of catatonic excitement. The patient may suddenly 
come out of the stupor, and it will then be discovered that he is 
partially or completely oriented as to time, place and person. 
He talks incessantly, paces back and forth, throws the furniture 
of the room about, breaks out the windows, makes senseless and 
unprovoked attacks on those about him, and may commit crimes 
such as homicide, assault and arson. Often he refuses his food 
and must be fed with a tube. He resists every effort to have 
him change his position. He resists natural impulses. He will 
refuse to take off his clothing. He will eat other patients' food 
rather than his own. He refuses to answer the calls of nature; 
urine will be retained until paralysis of the sphincter muscle and 
gravity causes the flow of urine. His conversation is usually 
an incoherent jargon. Often it is noted that there is a tendency 
to the coining or the senseless rhyming of words and phrases, MANUAL OF PSYCHIATRY 
170 
a symptom termed "nelogism." The following stenogram illus- 
trates this peculiarity: "How old are you?" "Shoe, fish, dish." 
"How do you feel?" "I have no plow in the field." How old 
are you?" "I have no cows, only bulls." "Where were you 
born?" "Fur and corn on a cow's horn." "Where are you?" 
"A bar is a bar and a car is a car." "What year is this?" "I 
want a bottle of beer while I am here." "Where do you live?" 
"I live in a sieve." "How do you like the weather?" "The cows 
in the heather." The patient quoted would keep up this incoher- 
ent conversation for hours at a time. 
The physical symptoms which accompany catatonia are simi- 
lar to those of the other forms of dementia prsecox, except that 
they are more marked. In the acute form of catatonia we find 
the patient suffering from constipation, headache and insomnia. 
The body is generally cold and covered with a disagreeable per- 
spiration. The hands and feet are usually cyanotic, due to 
marked disturbances of the capillary circulation. Dermato- 
graphia is common. The skin reflexes are often lost. The ten- 
don reflexes are usually increased. The pupils show a condi- 
tion of mydriasis. Sometimes they are irregular in size and the 
condition of hippus or clonic spasm of the iris is noted which 
is independent of the effects of light. Tuberculosis is a frequent 
cause of death in this type. About 60 per cent of the cata- 
tonic cases of dementia praecox end in a condition of terminal 
dementia. The general symptoms usually appear in the fol- 
lowing order: Depression; stupor, followed by excitement; de- 
mentia. Remissions are common in catatonic dementia prse- 
cox, and they last from a few hours to days or even months. 
It often appears that the patients have completely recovered. 
Relapses generally occur within a period of five years, but they 
may persist for as long as ten years. The catatonic dementia 
prsecox patients are more likely to commit crimes of a homicidal 
nature than are patients who suffer from the other forms. In DEMENTIA PRZECOX OR SCHIZOPHRENIA 
171 
about 30 per cent of the cases there develops only a mild 
type of dementia and the patients are able to return to their 
homes and assume occupations of a simple character. It is the 
consensus of opinion among observers that 13 per cent of the 
catatonic type make permanent social recoveries. Great num- 
bers of the catatonic patients die from intercurrent diseases, 
especially tuberculosis. 
Paranoid Type.-In this form of dementia praecox we have a 
rather loosely woven system of delusions. Four types have been 
recognized. In one group the delusions are arranged in a more 
or less orderly fashion. In the second group the delusions are 
of an expansive nature and are most often observed in women 
patients. In the third type the delusions are attended by con- 
fabulations and memory fluctuations. In the fourth type the 
delusions are of a very fantastic nature. 
The disease is ushered in, as a rule, by mental depression, 
insomnia, restlessness, malaise, muscular weakness, loss of appe- 
tite, loss of weight and general physical decline. The patient 
seeks solitude instead of companionship. Mental examination 
shows that he entertains a poorly constructed and unstable 
system of persecutory delusions. Not infrequently this class of 
patients entertains delusions of a grandiose nature. The author 
has had in his charge patients who believed themselves to be 
celebrities of history-Brigham Young, George Washington, 
Admiral Dewey, Napoleon, St. Paul and Elijah. One declared 
himself to be the Son of God and styled himself the "Spiritual 
Son of the Spiritual God of all towns and cities." Another 
believed himself to be a great astronomer and mathematician 
and declared that but for the machinations of the Masonic 
Lodge he would be a professor at some great university. Attend- 
ing these grandiose ideas in each case was silliness and dilapi- 
dation of thought and incoherent and irrelevant conversation. 
These patients decorated themselves with bits of paper, rags and 172 
MANUAL OF PSYCHIATRY 
rubbish to prove their absurd claims, and the astronomer drew 
maps of the heavens to establish the fact of his learning. One 
patient refused to eat because he feared he would be slaughtered 
if he gained in weight. The belief that food is poisoned is a 
common delusion. Auditory hallucinations are frequent and 
these are of a persecutory character, often having a sexual color- 
ing. Attending this condition are signs of progressive dementia 
which distinguish this order from true paranoia. 
The dementing process in the paranoid type is not so rapid 
in its development as in the other forms. This type is rarely 
punctuated by remissions, and after the disease has existed from 
one to three years there is usually a well-defined condition of 
mental deterioration which is more or less profound. Conscious- 
ness may remain unaffected for a long period of time, and 
orientation in all spheres may be only partially disturbed. 
Periods of excitement and depression are not infrequent. 
There is often noted a more profound form of paranoid 
dementia praecox in which all symptoms are markedly increased. 
To this type Kraepelin has given the name of paraphrenia and 
he divides the group into four classes, which are as follows: 
The fantastic type, in which the patients show very elaborate 
delusions, which, however, are disconnected and of a rapidly 
changing character. 
Second, a type marked by extensive confabulations. The 
delusions are expansive and paranoid and are usually made up 
of or built upon falsifications of memory. 
The third type is the expansive form, which occurs most 
frequently in women. The delusions are very expansive and 
are attended by a state of restlessness. 
In the fourth or systematic type the delusions are fairly well 
systematized, but the deterioration is quite marked. 
In the severe forms of paranoid dementia prsecox, patients are 
given to worrying about religion and metaphysical problems. DEMENTIA PR.-ECOX OR SCHIZOPHRENIA 
173 
They often fear they have committed some unpardonable sin, 
and they feel that as the result of their sinful actions they are 
the butt of ridicule and censure on the part of other persons. 
They feel that people are continually watching them, whether 
they are in their homes or in public places; that they are the 
objects of scurrilous remarks and libelous statements in news- 
papers. They grow very suspicious of their relatives; feel that 
their children desert them; that their marital partners are un- 
faithful. They believe that poison is put in their food; that 
their beds are charged with electricity; that enemies exert an 
untoward influence upon their minds; that they feel energy going 
out of the backs of their heads. They complain that the physi- 
cians in attendance constantly read their minds during the night 
and when they are at their meals. They feel that persons far 
distant shake hands with them and converse with them by means 
of telepathy; that noxious vapors are introduced through the 
keyhole into their rooms; that poison is put into their clothing; 
that medicines are put in their food to reduce or increase sexual 
desire. 
Consciousness may remain clear for a long time and orienta- 
tion may be complete in this form. Patients do not have insight 
into their condition. They may feel that they are abnormal, 
but they believe that their abnormalities are the result of the 
persecutions of their enemies. Reacting to their delusional 
beliefs, they exhibit states of anxiety and belligerency. Their 
conduct is regulated by their delusional beliefs. 
The paranoid form is chronic in its development and the 
deteriorating process is slower than in the other forms, but there 
is a gradual change in the disposition and a dilapidation of the 
mental powers. A mild deterioration or a marked state of 
dementia may develop within a period of three years. When 
the state of dementia obtains, patients are less irritable and in 
a more happy state of mind. 174 
MANUAL OF PSYCHIATRY 
Mixed Forces.-The mixed forms occur with greater regularity 
than do the single forms that have just been described. There 
is usually an admixture of the symptoms of the various groups. 
Diagnosis.-There are no pathognomonic signs of dementia 
praecox. The whole clinical picture must be considered in making 
a diagnosis. 
Paresis begins usually in the third or fourth decade, attended 
by a positive Wassermann of the blood and spinal fluid in most 
cases and by an increase in the cell count of the spinal fluid. 
The mental dilapidation develops with greater rapidity in 
paresis than in dementia praecox. The findings in the nervous 
system are characteristic in paresis and are absent in dementia 
praecox. 
Maniac depressive psychosis is sometimes confused with de- 
mentia praecox, especially in the manic phase. Catatonic stupor 
and the stupor of manic depressive psychosis in some ways are 
quite similar. Here the history in the manic depressive case 
will be of assistance. The general behavior of the manic 
depressive case indicates the possession of mental faculties. 
There is not the silliness of conduct or behavior without purpose 
as there is in dementia praecox. 
The hysteroid attacks of dementia praecox somewhat resemble 
the paroxysms of hysteria. However, hysterical individuals 
show some judgment and deliberateness of purpose in their 
paroxysms. The signs of a dementing process are absent in 
hysteria. 
In paranoia there is a slow development of the disorder. The 
delusions are supported by more or less logical arguments. They 
are not so phantastic and absurd as in dementia praecox. Until 
the very late stages of paranoia signs of dementia are not 
present. 
Psychology.-In all forms of this disorder there are found the 
following mental phenomena. Consciousness is clear, as a rule, DEMENTIA OR SCHIZOPHRENIA 
175 
except in excited or stuporous states. Hallucinations and delu- 
sions of sight, hearing and touch are common. The power of 
attention is impaired by blocking and aprosexia. Orientation 
remains unimpaired except when delusions concerning person- 
ality exist. The memory defects are more apparent than real, 
except in the terminal stages of the disease, when there is 
amnesia of the anterograde type. Ideation is impaired; the goal 
idea is absent. The judgment is impaired. The feelings and 
emotions show marked dilapidation. These symptoms owe their 
existence to a process of molecular splitting of the personality, 
a disintegration of the psyche which reduces mental life to lower 
and lower levels as the disease progresses. 
Treatment.-Prophylactic Treatment.-Whenever it is dis- 
covered that a child or adolescent individual is possessed with a 
shut-in personality, is extremely seclusive and avoids the usual 
activities suited to his years, an examination should be made 
as to his mental status. Vigorous efforts should be made to 
interest him in the usual pastimes, sports, occupations and 
studies of a normal individual of the same age. The sexual 
problems of puberty should be explained to this type of patient 
and the mysteries which usually shroud sexual matters should 
be made plain. The French say, in speaking of dementia praecox, 
that the patients were "stranded on the rock of puberty." This 
trite statement is many times a clear explanation of the develop- 
ment of dementia praecox. Psychoanalysis is of value in working 
out the problems of the shut-in personality and assists in point- 
ing the way to the re-education of the potential dementia praecox 
patient. After the disease has developed, the treatment in the 
main is custodial, hygienic and symptomatic. Some cases may 
be cared for in their homes, but it must be borne in mind that 
this sort of care is always attended by risk. The majority of 
cases must of necessity be treated in institutions, where the 176 
MANUAL OF PSYCHIATRY 
patients may receive the benefits of physiotherapy and occupa- 
tional therapy under the direction of qualified teachers. 
Medical Treatment.-The medical treatment is to be given 
with the view in mind to remedy whatever existing physical 
conditions need attention. The general health of the patient 
is to be restored. To this end free catharsis will be instituted in 
an effort to relieve the economy of toxins that may be present. 
The urine is usually diminished in amount and as a rule gives 
a highly acid reaction. Often the patient fails to pass his urine 
for many hours at a time, even allowing the bladder to overflow 
from distension. The retention of the urine no doubt adds to 
the toxic state of the patient. The administration of alkalies 
is of advantage in overcoming the acid condition of the urine. 
Education of the patient to relieve his bladder at stated intervals 
is an important measure. Hydrotherapy is a useful method to 
be employed for the purpose of relieving the system of toxins. 
If the patient is anemic, tonics containing iron and arsenic may 
be tried. Infected tonsils and decayed teeth are to be removed 
and all needed surgical procedures instituted. Glandular therapy 
is to be tried if there is evidence of dysfunction of the endocrine 
system or disturbance of the internal secretions of the testicle 
or ovary. In a word, the patient is to receive the same care 
as do sane patients in the relief of their ills. Too often it has 
been the practice to neglect the treatment of the patient, once 
the diagnosis of dementia prsecox has been attached to him. 
Hydrotherapy and mild hypnotic drugs such as veronal, 
sulphonal and somnos may be used to combat insomnia. Con- 
tinuous baths are of value in states of catatonic excitement. 
Warm and hot packs may be carefully employed for the same 
symptoms, under the direction of a physician. 
The food should be liberal and easily digestible. Refusal of 
food may be permitted for from twenty-four to seventy-two 
hours, depending upon the general nutrition of the patient. If 177 
DEMENTIA PR/ECOX OR SCHIZOPHRENIA 
at the end of that time the patient is not eating voluntarily, it 
is necessary to resort to feeding by means of the stomach tube. 
Frank discussion with the patient of his symptoms is many 
times of value in assisting him in regulating his conduct. Many 
institutions are finding that outdoor life in the form of gardening 
work is very successful in the treatment of both the acute and 
chronic cases. Occupational therapy assists the patient in pre- 
serving and promoting his powers of making adjustments to his 
environments. CHAPTER XVI 
PARANOIA AND PARANOID STATES 
It is still debated whether it is more accurate to speak of 
paranoia as a real psychosis or as an anomaly of mental develop- 
ment. There is much to be said on both sides of the question. 
The clinical picture of its onset and progression conforms in a 
general manner with the current conception of the term psy- 
chosis. The term paranoia has acquired a definite position in 
psychiatric literature and its use implies the existence of a 
definite clinical entity as set forth below. 
Definition.-Paranoia is a chronic, slowly progressive, incur- 
able mental disorder characterized by the formation of sys- 
tematized delusions which are built up in more or less logical 
forms. There is but a slight tendency to mental deterioration. 
This disorder may be arbitrarily divided into three stages, 
according to the character and the time of appearance of its 
principal symptoms. It may be arrested at any of its periods. 
The stages of this anomalous psychosis which gradually merge 
into one another are as follows: 
1. Stage of hypochondriasis or subjective analysis. 
2. Stage of systematized delusions of persecution. 
3. Stage of transformation of the personality. 
Etiology.-The underlying basis of this psychosis is a con- 
genitally defective nervous organization. Heredity is the most 
important factor for its production, and a study of the great 
majority of the cases shows that there is a family history of 
mental or nervous defect. The disease makes its appearance 
usually between the second and third decade, although it may 
178 PARANOIA AND PARANOID STATES 
179 
appear in any period of life. Approximately 1 to 5 per cent 
of all patients admitted to state hospitals for the insane suffer 
from this disease. Males are more frequently afflicted than 
females. Celibates of both sexes are more often found to be 
victims of this disorder than are married persons. In the major- 
ity of cases some form of mental or physical degeneracy is 
found. The following conditions have been described as exciting 
or precipitating causes of paranoia, but their causal relation is 
more apparent than real: 
1. Shock, physical or mental. 
2. Prolonged physical and mental 
3. Stress due to business failure. 
4. Acute illness. 
5. Excessive emotions. 
6. Mental and physical changes due to physiological causes. 
Pathology.-No demonstrable pathology has been found. 
At autopsy there has been noted by some observers, however, 
asymmetry of the brain, slight distortions of the convolutions, 
and anomalous forms of the cerebral vessels. The brains of 
those patients who live to the senile period show the character- 
istic changes of senility. 
Symptomatology.-1. Stage of Hypochondriasis or Subjective 
Analysis.-The prodromal period of this disorder, which usually 
has no definite onset, is ushered in by a train of neurasthenic 
symptoms which may last from a few months to several years. 
We usually find that the patients are persons who have been 
regarded as queer and eccentric from childhood. Many of them 
have been very precocious and exceptionally brilliant, but lop- 
sided in their mental development. Their eccentricities now 
become accentuated and emphasized. 
As the disease progresses the patient becomes morose and 
sullen. Periods of irritability present themselves. He prefers 180 
MANUAL OF PSYCHIATRY 
his own society; seeks solitude and quietness. His thoughts 
become so melancholy and depressed that he occasionally thinks 
of suicide, but this he rarely attempts. Gradually he loses his 
capacity for steady work and close attention to details of busi- 
ness becomes an impossibility because of the patient's ego- 
centric attitude. As a result he fails in business, and because 
of his failure he resorts to morbid investigation of the motives 
and behavior of his business associates. Introspection and self- 
analysis become extreme and the patient seeks in his past life 
for causes and explanations of his great mental depression and 
suspicions. He experiences peculiar sensory disturbances, chief 
of which are the tingling of the skin, the appearing of bright 
spots before the eyes, tinnitus aurium, insomnia, loss of appetite 
and a general feeling of ill-being. Gradually delusions begin 
to be erected upon this state of self-analysis and melancholy. 
Now he thinks that his friends are less friendly to him than 
they have been previously. He notices that they make signs 
at him as he passes on the street; that they talk about him in 
whispered tones; that they cough and clear their throats as he 
passes; that they wear certain types of clothes to irritate him. 
These ideas of suspicion and distrust are concerned not alone 
with his acquaintances. His home life ceases to be a pleasure. 
He entertains ideas of infidelity on the part of his wife and 
believes that his children show a perverse lack of filial respect 
and affection. 
The patient keeps secret his mental distress except for uncon- 
scious lapses of self-control which show that a gradual change 
is taking place in his mental disposition. He may be detected 
unawares recognizing the painful hallucinations which make 
their appearance as the disease passes into the second stage, 
the chief symptoms of which are systematized delusions of 
persecution of endogenous origin. PARANOIA AND PARANOID STATES 
181 
2. Stage of Systematized Delusions of Persecution.-The 
symptoms of the first stage are accentuated. His introspection 
and suspicion and mistrust of others destroy all his peace of 
mind. This is the period of explanation. He now understands 
that the insults, ill treatment and scorn he has received at the 
hands of his former friends are the results of attempts on their 
part to persecute him. He becomes convinced that his enemies 
are trying to ruin his business; that they are endeavoring to 
blacken his character because they are jealous of him. Often 
he feels that he is the victim of conspiracy of various institutions, 
such as the Catholic Church, the Jesuits, or the Masonic frater- 
nity. Often he believes that his food is poisoned; that noxious 
vapors are introduced into his room while he sleeps. He has 
auditory hallucinations; he hears voices accusing him of disgust- 
ing sexual crimes and practices. 
The ideas of persecution, no matter how ridiculous they appear 
to the normal individual, are defended by long trains of argu- 
ment more or less logical. The premises of his arguments are 
faulty, but he fails to perceive their inaccuracy. His delusions 
of persecution are unalterable and fixed and no amount of 
physical demonstration to the contrary can prove to him the 
falsity of his views. In spite of these gross delusions of perse- 
cution the consciousness of the patient remains clear, as do 
memory and the other intellectual faculties. 
During the second stage the paranoiac may be exceedingly 
dangerous to society, depending upon the character of his delu- 
sional beliefs. In many instances he is a potential homicide. 
The more sane he appears, the more dangerous he is. Many 
of them exercise considerable self-control and craftily hide their 
troubles and delusions in such a logical and plausible manner 
that physicians, lawyers and the public in general are deceived. 
Occasionally some paranoiacs seek to avenge their imaginary 
wrongs by litigation. In this way they make themselves ex- MANUAL OF PSYCHIATRY 
182 
tremely annoying to the public, for they often bring unfounded 
suits against the title to property, which the owners, in justice 
to themselves, are bound to answer. To this form of the disease 
has been applied the term litigious paranoia. The disease may 
be arrested in the second stage, the patient remaining a danger- 
ous element in society and in a state of mental torture and 
unhappiness due to the sharpness of his delusions, from which, 
through the advance of psychic deterioration, he receives no 
respite. 
3. Stage of Transformation of the Personality.-In the unar- 
rested cases the disease passes into the third stage. The patient 
now finds a satisfactory explanation of all the persecutions that 
have been heaped upon him. He becomes exceedingly egotistical; 
is very much pleased with himself and his attainments. The 
delusions change from a persecutory to a grandiose nature. He 
may now discover himself to be Napoleon, Washington, a king, 
or even Deity. The hallucinations which in the second stage 
were painful now become pleasant, and the voices heard come 
from God. It is in this stage that the paranoiac feels that he 
has a great mission to perform. He often prays and preaches 
to excess; frequently writes lengthy theses on religious subjects. 
Retrospective falsifications of memory are common. By this 
means he fills in his past history with arguments to prove that 
he is the great personage that he claims to be. 
The period of transformation of the personality may develop 
slowly and last for an indefinite time. Some cases progress to 
a condition of terminal dementia. The majority, however, 
remain stationary in one of the three stages described. 
According to the predominant character of the delusions we 
have the following principal classes of paranoiacs: 
Erotic paranoiacs, of which Mary Anderson's love is a type. 
Religious paranoiacs, exemplified by Mary Baker Eddy. PARANOIA AND PARANOID STATES 
183 
Political paranoiacs of the Booth type, who are murderers of 
prominent men. 
Ambitious paranoiacs, like Kaiser Wilhelm. 
Litigious paranoiacs-persons constantly bringing unfounded 
suits against corporations and wealthy people. 
Paranoid States.-Paranoid states are frequently a part of 
the symptomatology of the other psychoses, and these paranoid 
conditions are found after careful investigation to be a part of 
the symptom complex of other mental disorders, but after this 
delimitation has been made, mild paranoid states of a curable 
variety are very frequently found, which develop as a reaction 
in unstable and psychopathic individuals, in response to painful 
conflicts born of unpleasant circumstances. These paranoid 
states disappear when the environmental or psychogenetic fac- 
tors which produced them are relieved. These painful conflicts 
arise when individuals have been defeated in lawsuits or unjustly 
deprived of rights which belong to them, through the operation 
of legal technicalities. This type of paranoid state is sometimes 
called querulent insanity. Paranoid states are not usually 
attended by hallucinations. 
Diagnosis.-The diagnosis of paranoia as a rule is not diffi- 
cult, providing care is exercised to exclude the paranoid states 
of the other essential insanities. The insidious onset, the sys- 
tematized delusions, the transformation of the personality and 
the slight tendency to dementia make the diagnosis relatively 
easy. 
Paresis is to be distinguished from paranoia by the history, 
manner of onset, the great mental deterioration, the results of a 
Wassermann test of the blood and spinal fluid, and the exami- 
nation of the nervous system. 
Dementia prsecox is to be distinguished from paranoia by the 
progressive mental deterioration, the emotional indifference and 
the unsystematized delusions which attend this disorder. 184 
MANUAL OF PSYCHIATRY 
Maniac depressive insanity is marked by recurrent attacks, 
alternate periods of elation and depression, and the absence of 
systematized delusions. 
Prognosis.-The prognosis is unfavorable. Genuine cases of 
paranoia do not recover, though occasionally the disease is 
arrested early in its course and the individual, if his delusions 
are harmless, may be able to adjust himself to society for a long 
period of time without difficulty. 
Treatment.-Treatment by medication is unavailing in para- 
noia. The majority of cases require institutional treatment, for 
the patients find it difficult or impossible to adjust themselves 
to social conditions and are potentially a source of danger to 
life and property. There are exceptions to this rule. Some 
paranoiacs who entertain harmless delusional beliefs may live 
outside of institutions without danger to other persons, provided 
they are relieved of the strain of irritating circumstances and 
placed in comfortable situations. Psychoanalysis is of benefit 
in the treatment of the mild type of paranoia, for by this method 
the patient is enabled to overcome to a degree his mental conflict. 
It must always be borne in mind, however, that a seemingly mild 
paranoiac may at any time display dangerous tendencies. CHAPTER XVII 
EPILEPTIC PSYCHOSES 
Definition.-The epileptic psychoses include all the psychic 
disturbances which attend the epilepsies. Chief of these psy- 
chotic symptoms are states of irritability, excitement, stupor and 
automatism, and periods of confusion and befogged and de- 
lirious conditions. According to the time of appearance of 
the mental disorders, they may be divided into preparoxysmal, 
paroxysmal and intraparoxysmal types. 
Etiology.-Various percentages have been given by different 
authors as to the hereditary factor in the production of epilepsy. 
Spratling stated that 56 per cent of his patients gave a history 
of neuropathic heredity and that 16 per cent were born of parents 
who suffered from epilepsy. Others have stated that at least 
80 per cent of epileptics come of tainted stock. It has been found 
that tuberculosis and alchoholism are common in the parents of 
epileptics. Wildermuth considers alcoholism in the parent a 
most potent cause of epilepsy. Infectious and constitutional 
diseases in the parent, such as syphilis, nephritis, rheumatism, 
diabetes and chorea, seem to dispose the offspring to epilepsy. 
Three to 4 per cent of epilepsy may be charged to traumatism 
to the head or spine. The following conditions have acted as 
precipitating factors for the production of epilepsy: 
Physical 
Traumatism to head and spine 
Sunstroke 
Metallic poisons 
Infectious diseases 
Gastro-intestinal disorders 
Valvular heart disease 
Carious teeth 
Alcoholic excesses 
Intestinal parasites 
Phimosis. 
Psychic 
Emotional shock, as great fright 
Excitement 
Continued anxiety 
Grief 
Psychic trauma of a sexual nature 
185 186 
MANUAL OF PSYCHIATRY 
Pathology.-The exact causative pathology of epilepsy is 
still unknown and a matter of dispute, but it is the consensus 
of opinion that it is a cortical disease, and at post mortem in 
idiopathic epilepsy sclerosis of Ammon's horn is usually found. 
It is believed that the cortical changes are the result of chemical 
poisons of an endogenous character. The following pathological 
conditions have been found at post mortem: 
Gross Pathology 
Deformities of the skull, develop- 
mental and acquired; exostoses 
General thickening of the skull, 
particularly in the occipital region 
General congestion of the meninges 
Calcareous deposits in the meninges 
Adhesions of the dura mater to the 
calvarium 
Edema of the pia mater 
Opacity and thickening of the pia 
mater 
Sclerosis of Ammon's horn 
Tumors-(a) gliomata, (b) sarco- 
mata, (c) carcinomata, (d) cysts 
Arteriosclerosis 
Thrombosis 
Embolism 
Hemorrhage 
Patulous foramen ovale 
Stenosed cardiac vessels. 
Microscopic Pathology 
Perivascular gliosis 
Hypertrophied neuroglia cells 
Degenerative changes in the nerve 
cells 
Chromatolysis of nerve cells and 
neuroglia 
Infiltration of the cortex with 
leukocytes 
Capillary endarteritis. 
Symptomatology.-Preparoxysmal Symptoms.-There usu- 
ally precedes the epileptic seizure of a prodromal period varying 
in length from a few hours to several days. This state is charac- 
terized by a train of mental symptoms, i. e., the normally peace- 
ful, good-natured individual becomes high-strung, morose and 
irritable. In this state the slightest trivialities are sufficient 
to produce outbreaks of temper and acts of violence. In some 
patients we find depressive and melancholy states which border 
on stupor. Other patients suffer from insomnia, have headaches 
and malaise, terrifying dreams, entertain delusions of persecution, EPILEPTIC PSYCHOSES 
187 
have visual hallucinations, and more rarely exhibit auditory 
hallucinations. The patient often behaves as an automaton just 
before the convulsive attack. The mental operations in a pre- 
paroxysmal period are inaccurate, sensation is disordered. Con- 
ditions of parasthesia are common. The patient sees lights, has 
visions, smells vile odors. Reason and judgment are markedly 
faulty. Epileptic furores sometimes take place. Acts of vio- 
lence are occasionally committed. Religious tendencies are 
especially noticeable during the period preceding a convulsion. 
The patient often reads the bible for hours at a time, preaches 
and prays, and has visions of an ecstatic nature, but if he is 
disturbed in his mystical meditations he gives way to a violent 
explosion of wrath. 
Paroxysmal Symptoms.-The convulsive seizures in epilepsy 
may be the following varieties: 
Petit Mal. 
Grand Mal. 
Jacksonian. 
Petit Mal.-In this condition the patient loses consciousness 
for a very few seconds. His face blanches and his eyes become 
fixed. He stops in his conversation or work, and then shortly 
resumes his activities. This form is not attended by convulsive 
movements and is likely to be overlooked by those not familiar 
with it. The term "absence" is sometimes applied to this 
condition. 
Grand Mal.-The convulsion may be preceded by an aura in 
which the patient sees light, has tingling sensations, hears voices, 
or experiences other phenomena. The aura is usually followed 
by a cry which is so characteristic that it has earned the name 
of epileptic cry. The patient is thrown down and is completely 
unconscious. The body goes into a tonic state, which is followed 
by clonic convulsions. The tonic convulsive state usually occu- 188 
MANUAL OF PSYCHIATRY 
pies about thirty seconds. There is general muscular tension, 
the head is twisted to one side or bent backwards, the eyes are 
turned backwards and upwards, the face becomes cyanotic and 
breathing is labored. The tonic phase is then succeeded by 
clonic convulsions which may at first be localized and then 
involve the whole body. There may be rhythmic jerking of the 
extremities, grinding of the teeth and frothing at the mouth. 
Often the tongue is bitten and the sputum tinged with blood. 
The movements gradually cease, the patient becomes quiet, and 
the face resumes its normal color. The convulsive attack may 
last from two to five minutes. Sphincteric control is often lost 
during the convulsive period. Ejaculations of semen occasionally 
occur. The tendon and skin reflexes are usually absent during 
the convulsion and immediately afterward. The pupils do not 
react to light and the cornea is insensible. The Babinski reflex 
is frequently found. Occasionally there is an elevation of tem- 
perature. An examination of the urine immediately following 
a paroxysm shows that it is loaded with organic salts. The 
convulsive attack is generally followed by a period of sleep, 
somnolence and stupor. The epileptic convulsions may be re- 
peated without an interval of consciousness, which condition 
is known as status epilepticus. This phenomenon is attended 
by elevation of temperature and often results in death. 
Jacksonian.-In this condition there are found spasms of 
groups of muscles. It may occur in the leg, arm, hand or face. 
The convulsive attack is clonic and not attended by loss of 
consciousness as a rule, but the convulsion may start from one 
group of muscles and continue until the entire body is involved, 
at which time consciousness is lost. The convulsive attacks may 
be diurnal or nocturnal. 
Post Paroxysmal Symptoms.-Usually following the epileptic 
seizure the patient lapses into deep sleep, but there may be 
periods of maniacal excitement in which he is talkative, impul- EPILEPTIC PSYCHOSES 
189 
sive, easily irritated, and inclined to commit dangerous acts. 
The patient acts as though he were in a dream; he is an auto- 
maton. Crimes are quite frequent in this period. 
Intraparoxysmal Symptoms.-The mental symptoms charac- 
teristic of this period are the accentuation of the disagreeable 
epileptic character, which is marked by states of irritability, 
outbursts of passion, fits of melancholy and depression. States 
of confusion are observed. Clouding of consciousness, delusions 
and hallucinations of a persecutory character have been noted. 
Homicidal and suicidal tendencies are exhibited. Occasionally 
the epileptic is peaceful, quiet and excessively good-natured. 
Others are extremely sentimental and show excessive religiosity. 
As a class they are unreliable in their statements, are given to 
marked exaggeration, are childish in their behavior and are often 
given to sexual excesses. 
Psychic Epilepsy.-In this type the convulsive attack is re- 
placed by episodes of excitement. The condition resembles the 
dream states of hysteria. It may last for a few hours or several 
days. During this time the patient performs acts automatically 
but with apparent consciousness. He replies to questions in a 
vague, incoherent manner and wanders aimlessly about his home. 
Cabmen have driven their vehicles, mothers have dressed their 
children, janitors have done their usual duties and artisans have 
carried on acts in line with their work, while in this condition. 
Persons have traveled many miles by rail and otherwise and 
have regained consciousness long distances from their homes, 
while in the state of psychic epilepsy. 
Criminal acts are common in attacks of psychic epilepsy. 
Homicide, suicide, arson, rape and larceny have been committed. 
When the attack has passed the patient has no memory for the 
period or for the violent acts he may have committed. The 
condition of psychic epilepsy furnishes the basis for exceedingly 
delicate and difficult medico-legal contentions. Where crimes 190 
MANUAL OF PSYCHIATRY 
have been committed without apparent motive, epilepsy is to be 
borne in mind. (See chapter on crimes of the insane.) 
Diagnosis.-The diagnosis of the epileptic psychoses is usu- 
ally easy when a history of repeated convulsions is obtainable 
or where the physician has observed the patient in a convulsion. 
Hysteria.-The convulsive attacks of hysteria have been de- 
scribed elsewhere. (Page 201.) 
General Paresis.-Convulsive attacks occur in general paresis 
frequently from the time of its inception until its termination. 
Neurological examination and the Wassermann reactions of the 
blood and spinal fluid are sufficient to clear up the diagnosis. 
Alchoholism.-Following excessive indulgences alcoholics often 
have epileptic seizures which are vulgarly termed 11 whiskey fits." 
The history of the patient and his habits and general appearance 
are usually sufficient to clear the situation. 
Cerebral Syphilis.-In this disease convulsive attacks are often 
observed. The Wasserman examination of the blood and spinal 
fluid, together with a neurological examination, are sufficient to 
differentiate this disease from epilepsy. 
Senile Psychosis and Arterio-Sclerotic Dementia.-Convulsions 
are frequent in these diseases. The age of the patient and the 
focal symptoms are pathognomonic. 
Uremia and Diabetes.-Examination of the urine in these two 
diseases and the general condition of the patient distinguish 
them from epilepsy. 
Psychology and Nature of Epilepsy.-The existence of idio- 
pathic or essential epilepsy is dependent upon inherent constitu- 
tional defectiveness. All the mental processes, as time goes on, 
sink to lower and lower levels. Often this deterioration is so 
profound as to terminate in dementia. 
From a psychogenetic point of view the "fit" is regarded as a 
regressive reaction to unconsciousness in order to avoid the pain- 
ful realities of life. This viewpoint is not always tenable. EPILEPTIC PSYCPIOSES 
191 
None of the theories advanced adequately explains this dis- 
order and it still remains a mystery. The hypothesis of cortical 
instability would account for the convulsive attack on the ground 
that the neurones are in a constant state of irritability and are 
subject by this reason to explosions by slight stimulation. The 
circulatory theory that the fits are produced by cerebral anemia 
due to fall of blood pressure through vasomotor constriction or 
intravascular clotting is interesting but inadequate. The general 
treatment of epilepsy lends considerable credence to the belief 
that the disorder is due to autointoxication, possibly of endocrinal 
origin. Spratling has set forth the theory that the sensory cells 
in the second layer of the cortex are destroyed by some toxic 
substance and that a pronounced gliosis takes place following 
this destruction, leading to the conclusion that epilepsy is "a 
sensory disease with a motor manifestation." 
Prognosis.-The prognosis depends upon the cause of the 
epilepsy. In idiopathic epilepsy it is the consensus of opinion 
that each epileptic convulsion is attended by more or less im- 
pairment of the mental powers. This deterioration, however, is 
so insidious that in some cases it is scarcely perceptible. The 
older the patient, the poorer the outlook. The most frequent 
termination of chronic epileptic insanity is a state of terminal 
dementia. About one-half of the patients die as a result of 
injuries which they suffer during epileptic convulsions. 
Treatment.-The patient should lead a quiet, well-regulated 
life, free from excitement and worry. He should not engage 
in occupations involving the use of sharp tools or machinery, or 
in which he would be in danger of falls from a height. 
Meats should be eliminated from the diet so far as possible. 
Only the minimum amount of proteids should be allowed. Expe- 
rience and dietetic investigations have conclusively shown that 
the number of the convulsions and the intensity of them are 
increased by the indulgence in foods rich in proteins. Epileptics 192 
MANUAL OF PSYCHIATRY 
as a rule eat their food in a voracious manner. Patients should 
be cautioned against this practice. The bowels should be kept 
well regulated. Constipation seems to be attended by the pro- 
duction of convulsions. 
The frequency of the seizures may be controlled by the careful 
administration of the bromides. Lately luminal has come into 
use and in many cases it has reduced the number and severity 
of the convulsive attacks. In some instances it has failed and 
has proven even to be injurious. Sedatives reduce the number 
of the convulsions, but it is the consensus of opinion that the 
severity of the convulsive attacks is increased by the reduction 
in their number. 
Life in a rural community has been found to be of great ad- 
vantage. The motor energy of the patient should be released 
or discharged by useful daily employment. When his mental 
capacities are so disordered and deteriorated that he is dangerous 
to himself or others, he should be committed to an institution 
especially designed for epileptics, or to a properly equipped 
hospital for the insane. CHAPTER XVIII 
THE PSYCHONEUROSES AND NEUROSES 
Within this group are classified the reactional types of mental 
and nervous disorders which are without demonstrable physical 
basis and appear to be of purely psychogenetic origin. It is 
held by some authorities that the existence of any of these dis- 
orders is evidence in itself of constitutional psychopathic infe- 
riority. There is some ground, however, to take issue with this 
view. The following types of this group have been clearly 
defined: 
1. Hysteria. 
2. Psychasthenia. 
3. Neurasthenia. 
4. Anxiety or Dread Neurosis. 
HYSTERIA 
Definition.-Hysteria is a psychoneurosis which occurs usu- 
ally in individuals who possess highly neurotic and unstable 
constitutions. The disease is manifested by emotional episodes, 
increased susceptibility to external impressions, periods of de- 
pression, and marked sensory, psychic and motor disturbances. 
Etiology.-The most important factor for its production is 
the influence of heredity. A family history of insanity, epilepsy, 
chorea or alcoholism is found in about 80 per cent of the cases. 
It was formerly thought to occur infrequently in the male sex, 
but it is an established fact that males suffer to the same degree 
as females. The disease usually makes its appearance in early 
adult life, usually between the ages of fifteen and thirty years, 
although it may occur both earlier and later. Hysteria is often 
193 194 
MANUAL OF PSYCHIATRY 
associated with the organic psychoses. Faulty education and 
poor home environment are important factors in its production. 
Those conditions which lead to the exhaustion of the general 
health and vitality act as precipitating factors in persons pre- 
disposed by a defective nervous organization. The exciting 
factors are as follows: 
Mental Factors 
Fear 
Worry 
Psychic trauma 
Faulty environment 
Defective education 
Repressed painful ideas, usually 
sexual. 
Physical Factors 
Injuries 
Syphilis 
Alcoholism 
Infectious diseases 
Exhaustive diseases 
Disordered sexual functions. 
Hysteria remains one of the puzzles and unsolved problems 
of medicine. The mechanism of its development is still a ques- 
tion of dispute and various hypotheses have been advanced to 
account for its development. Among them the following are the 
most important: 
MECHANISM or HISTEHIA. 
Cleavage of Consciousnees: Separation of a painful group of ideas from 
the main body of consciousness, producing a conflict the results of 
which are converted into three main groups of symptom as Indicated by 
the diagram. 
pRyohio Symptoms. 
Gff grouji 
of painful 
idea*. 1 
Aboulia 
Amnesia 
Confusion 
Delirious states 
Impairment of thinking 
Impressionability 
Irritability 
Stupor 
Line of conflict 
between group of 
painful ideas and 
main body of con- 
sciousness* 
Convention of conflict into 
Sensory Symptoms. 
Anesthesia 
Blindness 
Acroparesthes ia 
Analgesia 
Concentric contraction of ritual 
field 
Coxalgia 
Globus hystericus 
Hysterical olavus 
Neuralgias 
Spinal irritability 
Motor Symptoms. 
fltein body of consoioua- 
l B06B. 
Astasia abasia. 
Choreio movements 
Convulsions, major and minor 
Contractures 
Hysterical dyspnea 
Tios 
Tremors 
Paralyses of various types and 
degress. THE PSYCHONEUROSES AND NEUROSES 
195 
Babinski has classified all symptoms which may be produced 
by suggestion and removed by persuasion as hysterical. To 
this condition of suggestibility he has applied the term Pithiatism. 
Any symptoms found which cannot be produced and removed 
by this method are regarded by Babinski as other than hysterical. 
Sollier maintained that hysteria is a condition resulting from 
a state of inactivity or sleep of the higher cerebral centers. 
Janet advanced the idea that in hysteria there is a disasso- 
ciation of certain painful ideas and a splitting up of conscious- 
ness; a condition in which there is a retraction of certain parts 
of consciousness. 
Others have maintained that hysteria is a type of mental 
reaction occurring in individuals who are mentally still children; 
whose minds are in a plastic state and extremely susceptible to 
suggestion. 
Freud has formulated the theory that hysteria is the result 
of sexual repression. According to him the hysterical individual 
has attempted to submerge in consciousness a group of painful 
ideas, and out of this attempt at repression there has grown a 
conflict between the individual's natural erotic desires and the 
moral conceptions he has attained through his environment and 
the process of education. An individual may suffer a shock of 
mental or sexual character which is attended by great emotional 
distress, and as a result there is split off from the main body 
of consciousness a group of painful ideas. This group of split-off 
ideas continues to enlarge and takes on a dynamic character. 
There develops a conflict between the main body of consciousness 
and the split-off constellation of ideas, and out of this conflict 
there may develop, through the process of conversion, three dif- 
ferent types of symptoms. In some persons the symptoms take 
on a sensory form alone, and there are disturbances of sensation 
such as anesthesia, paresthesia, acroparesthesia and constriction, 
of the visual fields. In others the symptoms are chiefly motor 196 
MANUAL OF PSYCHIATRY 
and there may be paralyses of groups of muscles or of a limb 
or of half of the body. Again, there may develop convulsions 
of minor or major character. The third group of symptoms may 
be chiefly psychic in character. There is an increased suscepti- 
bility to external stimulation. There are periods of forgetful- 
ness, defects of apprehension, dream states which resemble 
epilepsy and alcoholism, and disorders of volition shown by 
eccentric, silly and infantile conduct. Occasionally there are 
observed so-called double or multiple personalities in which the 
split-off group of ideas has become so enlarged and powerful 
as to assume the dignity of a personality. 
Symptomatology.-While the symptoms may be classified 
under the three following headings, they do not, as a rule, exist 
alone, as indicated in this specific classification. The symptoms 
may appear in any combination in any case. 
Psychic Symptoms.-In the minor form of hysteria the patients 
are extremely nervous and excitable. They cry and laugh with- 
out sufficient cause and are unable to control their actions. They 
not infrequently show a tendency to moral perversions and exces- 
sive eroticism. Often, however, erotic desires are apparently 
absent. In the major form hallucinations of a transient char- 
acter are found, which usually take on a religious or erotic 
coloring. Profound depressions occur, as do states of muttering 
and delirium and conditions of somnambulism. The emotions 
fluctuate; excessive good humor and marked irritability fre- 
quently alternate. The patients have a lively imagination; 
exaggerate all their symptoms. They seem to regard their dis- 
ease as a mark of distinction. In spite of their protestations 
of suffering, the patients will make tremendous mental and 
physical efforts to entertain themselves. They exhibit enormous 
amounts of self-pity, work upon the sympathies of philanthropic 
individuals, tyrannize over their friends and relatives and display 
excessive willfulness. They are often very vain and spend a THE PSYCHONEUROSES AND NEUROSES 
197 
great deal of time decorating themselves and pay elaborate 
attention to their clothing and general appearance. 
Sensory Symptoms.-The symptoms under this head some- 
times closely resemble those found in organic disease. Hemi- 
anesthesia is occasionally noted, especially on the left side of 
the body. Again, there may be islets of anesthesia in scattered 
portions of the body. The patient may be deeply pricked with 
needles in the anesthetic portions without giving the slightest 
evidence of sensation. Owing to a condition of ischemia there 
is no bleeding at the point of the needle prick. The cornea and 
the mucous membrane of the mouth are often insensible to touch. 
Reduction in the acuity of the special senses is often noted; 
hearing, smelling and tasting are defective. The muscle sense 
is frequently impaired. If the eyes are closed the patient is 
unable to touch the anesthetic parts. Conditions of blindness 
are occasionally seen, and while the pupils react to light and 
accommodation, the patient may be unable to see. Concentric 
constriction of the visual field is very common. Spots of hyper- 
esthesia are common on the head at the site of the sagittal suture, 
over the trunk, back and front of the chest, and along the spine. 
The patient often complains of pain in the bladder or urethra 
or of pains and slight swellings about the joints. Phantom tumors 
that sometimes lead to the diagnosis of pregnancy are encoun- 
tered. Two characteristic symptoms which were once thought 
to be pathognomonic, are observed. One is the distressing head- 
ache known as hysterical clavus. The patient feels as though a 
nail or spike were being driven into the head. The other symp- 
tom, to which the term globus hystericus has been applied, is 
that of a ball in the throat. Hemorrhages in various portions 
of the body have been noted. Gastro-intestinal symptoms such 
as gaseous distention, pain, vomiting and diarrhoea are observed. 
The patient is often troubled with a persistent, spasmodic cough 
or by attacks of dyspnea. 198 
MANUAL OF PSYCHIATRY 
Motor Symptoms.-The patient may have spasms of groups of 
muscles or of one arm or leg, or half of the body may be involved. 
The paralyses are usually of a flaccid character, the electrical 
reactions are normal, and if atrophy occurs it is of the disuse 
variety. The left side of the body is most frequently affected. 
The paralyses and contractures disappear under narcosis with 
chloroform or ether, and often under hypnosis. The muscles 
involved in the paralyses are usually anestheticized. The paraly- 
ses are usually temporary, though at times they may be very 
obstinate to cure and become more or less permanent. Convul- 
sions occur which are sometimes confused with epilepsy. A 
careful investigation of the convulsive attack leads to correct 
diagnosis. The convulsive attack is usually preceded by a pro- 
dromal period of nervousness, anxiety, a sense of choking or the 
dancing of bright specks before the eyes. Instead of falling to 
the floor or ground or being thrown down by the violent contrac- 
tion of the muscles as is the case in true epilepsy, the patient 
simply slides to the floor or bed or into some comfortable spot. 
It very rarely happens that the hysterical patient hurts himself 
in falling. There may or may not be a slight change in the color 
of the face. In some instances the breath is held and a blueness 
of the face is produced, but it is not identical with the cyanosis 
found in epilepsy. In the hysterical convulsion all the body 
muscles may be involved, or the spasms may be limited to one 
side of the body alone. The movements are often violent and 
extreme. There may be opisthotons. Again, the patient may 
violently pound the floor with his heels; the arms may be swung 
in all directions. There is a tendency for the paroxysm to 
increase in violence in proportion to the number of sympathetic 
onlookers. The patient pulls out his hair, tears the bedclothing 
or his own clothing, and laughs and weeps in turn. He never 
bites his tongue but may occasionally bite the lower lip. He 
may froth at the mouth but the spittle is not tinged with blood. THE PSYCHONEUROSES AND NEUROSES 
199 
The attack may last from a few minutes to several hours. While 
consciousness may be somewhat clouded and befogged, real un- 
consciousness does not occur. The patient may be roused by 
shaking, shouting, a dash of cold water or an electric shock. 
Sphincteric control is not lost, as it often is in epilepsy. The 
corneal and skin reflexes are often absent, but the tendon reflexes 
are always present in hysteria. In true epilepsy the Babinski 
phenomenon is found, but never in hysteria unless the psycho- 
neurosis is associated with organic brain disease. After the 
convulsive seizure is ended the patient may be so fatigued as to 
go to sleep, but the sleep is not the deep, stertorous one which 
follows a true epileptic convulsion. In some of the severe types 
of hysteria the paroxysm may be followed by a mild state of 
confusion or even stupor. There is no disturbance of the tem- 
perature in the hysterical convulsion, and death does not occur 
as a result of it, no matter how frequently the paroxysm may be 
repeated. Examination of the urine after the paroxysm shows 
it to be very pale, of low specific gravity, and devoid of organic 
salt, while in epilepsy the organic content of the urine is in- 
creased following a paroxysm. The hysterical attack may be 
stopped by suggestion, by mild censure or firm command, by 
the application of cold water to the face, and by the spraying 
of ether or chloroform upon the hysterogenic zones, as the 
breasts, the ovarian region and the testicles. 
Diagnosis.-The chief points to be considered in making the 
diagnosis are the history and temperament of the patient, and 
the presence or absence of the stigmata of hysteria. The char- 
acter of the hysterical convulsion is radically different from that 
of the epileptic type of seizure, as has been shown above. 
Dementia Pr&cox.-This is to be differentiated from hysteria 
by the presence of marked emotional deterioration, slow pro- 
gressing dementia, and the chronic nature of the disease. 200 
MANUAL OF PSYCHIATRY 
Prognosis.-The prognosis in hysteria is good so far as the 
attacks are concerned. The disease in itself is not progressive 
and mental deterioration does not take place. The younger the 
patient the more favorable the outlook. The disease is more 
persistent in males than in females, and the male patient is 
likely to take on states of depression during hysteria which are 
obdurate to treatment. The outcome of hysteria associated with 
organic disease is unfavorable. 
Hystero-Epilepsy.-There is no such disease entity as hystero- 
epilepsy. Hysteria and epilepsy may be associated, and by a 
careful method of diagnosis the co-existence of these two diseases 
may be discovered. 
Treatment.-Various drugs have been recommended, though 
none seems to exert specific reaction, although mild hypnotics 
in small doses may be used symptomatically. The paroxysm 
may be cut short by a cold douche or the injection of a fifteenth 
or twentieth grain of apomorphine. Suggestive therapeutics if 
properly employed will yield good results. It is necessary to 
seek out the psychic cause that precipitated the attack. Psycho- 
analysis is of great value in many of these cases. If possible 
the results of faulty education should be removed. The patient 
should be given a new outlook on life. It is useful to explain to 
him that the energy consumed in convulsive attacks should be 
diverted into useful and constructive channels. Occupational 
therapy is to be employed in attaining this result. Life out of 
doors and vigorous exercise is essential in physically strong 
patients. Hydrotherapy in the form of hot and cold douches 
and cold packs has a tendency to promote recovery. The patient 
should be isolated from his family and sympathetic friends. The 
general condition of the patient should be improved by hygienic 
living. Moderate exercise in the fresh air, light, nutritious diet, 
and the avoidance of excess of all kinds, are to be employed as 
routine treatment. Faradic electricity may be used in conditions THE PSYCHONEUROSES AND NEUROSES 
201 
of paralysis, anesthesia and hyperesthesia, to increase the gen- 
eral nutrition of the parts and for its psychic effect. Hypnotism 
has been employed in some cases, but it is the consensus of 
opinion that hypnotism, except in very rare instances, is likely 
to produce more ill effects than good. 
SYNOPTICAL TABLE OF THE CAUSES OF MENTAL DISEASES 
CONVULSIONS 
Differentiation between Epilepsy and Hysteria 
Epilepsy 
Hysteria 
1. Aura 
Common in epilepsy; numb- 
ness or prickling; somatic 
sensations. 
Emotional outbreaks. No 
true aura. 
2. Onset 
Sudden. Patient falls vio- 
lently wherever he may be. 
Emotional disturbances pre- 
cede. May occasionally be 
sudden. 
3. Conscious- 
ness 
Loss of consciousness sudden 
and complete. 
Seldom completely lost. Pa- 
tient easily aroused by stim- 
ulation. 
4. Character of 
convulsion 
Tonic at first, then clonic. 
Stertorous breathing. 
Irregular; may be tonic or 
clonic. Clownish, erotic at- 
titudes; opisthotonos. Worse 
when there are observers. 
5. Duration 
Of short duration; one to 
four minutes. 
Five minutes to an hour, or 
even longer. 
6. Termination 
Usually slow return to con- 
sciousness, often followed by 
deep sleep or hebetude. 
Soreness in muscles. 
May or may not be followed 
by sleep. No hebetude. 
7. Pupils 
Usually dilated; immobile; 
do not respond to light. 
Usually dilated. Irregular 
movements of eyeball; 
twitching of eyelids. Anes- 
thesia of cornea often pre- 
sent. 
8. Sphincteric 
control 
Often lost in epilepsy. Blad- 
der and bowels often evacu- 
ated. 
Practically never lost. 
9. Scars 
Face scarred; tongue bitten; 
other injuries to body due to 
falls. 
No scars; tongue not bitten; 
no injuries. Lower lip occa- 
sionally bitten. 
Not elevated. Normal. 
10. Temperature 
Often an elevation of one or 
two degrees. 
11. Urine 
Solid matter of urine in- 
creased. 
Limpid; solid matter not 
increased. 202 
MANUAL OF PSYCHIATRY 
PSYCHASTHENIA 
Definition.-Psychasthenia is a mild type of non-dementing 
psychosis occurring in individuals of constitutional inferiority. 
It is characterized by the exhibition of a long train of neuras- 
thenic symptoms and emotional, volitional and intellectual 
obsessions. 
Etiology.-Approximately seventy-five per cent, of the 
patients suffering from this disorder give a family history of 
neuropathic taint. The disease may be developed upon an 
acquired constitutionally defective state produced by infectious 
diseases, injuries, hemorrhages, the use of alcohol and the effects 
of syphilis. About 50 per cent of the psychasthenics show some 
of the stigmata of degeneracy. The disease affects both sexes 
alike. It may appear at any age, but occurs most frequently 
between the second and fourth decade. 
Pathology.-There is no demonstrable pathology. 
Symptomatology.-The basic symptom of this disorder is a 
state of mental inadequacy. All mental operations, while started 
in the proper manner and possibly in the right direction, fall 
short of the goal idea, and in like degree the reactions of the 
individual to his environment are always below the point of 
adequate adjustment. The following illustration will serve to 
explain psychasthenia. The goal of adjustment may be repre- 
sented by 1,000 yards and the psychasthenic patient's mental 
capacities may be compared to a bullet which has behind it the 
explosive power to send the missile 700 yards. The original 
charge of potential is too small. The patient fails to interpret 
the conditions of reality in the proper manner. He sees life 
"through a glass, darkly." This imperfection perception of life 
leads to feelings of mystery, fear and anguish when the patient 
comes in conflict with his environment. 
Three types of obsession are common in psychasthenia and we THE PSYCHONEUROSES AND NEUROSES 
203 
may divide these into the intellectual, emotional and volitional, 
according to the content of the obsession. 
Intellectual Obsessions.-The most important among these are 
ideas of a metaphysical nature. The psychasthenic asks, What 
is God? Is there a God? Is there such a thing as a standard 
of morality? Can perfect morality be attained? The psychas- 
thenic writes books and pamphlets to start schools of new 
thought; explains his ideas to anyone who will listen to him. 
His conduct is so regulated by these obsessions that he neglects 
the practical questions of life. He is a day-dreamer; never 
measures up to the practicabilities of life. 
Emotional Obsessions.-The psychasthenics have all manner 
of fears and morbid desires. They are afraid of open places- 
agoraphobia. For this reason they avoid crowds; avoid the 
business districts of cities; stay in their own homes. Others 
suffer from just the opposite fear-claustrophobia. They fear 
closed-in places. They must always be in the open; are afraid 
to stay in their rooms by themselves; afraid to use elevators 
in public buildings; experience great distress in attempting to 
take a bath in a closed room. Sitophobia is often noted. When 
the patient suffers from this obsession he fears to take his food, 
eats very little, loses weight and develops a condition of mal- 
nutrition because of his senseless fears. Others suffer from 
misophobia, the fear of dirt. After touching any article they 
resort to ablutions. After turning a doorknob the hands must 
be cleansed. They pick up a book; the process is repeated. The 
patients live in a frenzy of scrubbing and cleaning. Astraphobia, 
a fear of thunder, lightning and storms, is a common obsession. 
Conditions of aerophobia, a morbid fear of high places, are 
found. Patients fear to go into the top floors of high buildings 
or upon ladders or stairs; are afraid to get off the ground or 
floor. These phobias are more or less constant in most patients 
but occasionally they are found to exist only at times, and then 204 
MANUAL OF PSYCHIATRY 
they are acute. The patient often fully appreciates the absurdity 
of his fears, yet in spite of understanding them he is unable to 
control his emotions when his obsession is acute. When the 
patient suffering with aerophobia is forced to ascend into high 
places the face blanches, a cold perspiration breaks out, the 
knees shake, and the teeth may chatter. Not until he is relieved 
of the situation which produced the phobia does he return to 
normal. 
Morbid Desires.-The morbid states of the psychasthenic are 
well known. Chief among these are the conditions of dipso- 
mania and morphinism. The patient is urged on by a wild desire 
to indulge in liquor or morphine. The morbid craving is accom- 
panied by feelings of distress, such as headache, tachycardia 
and dizziness. Just so soon as the patient yields to the morbid 
desire these feelings pass off. 
Volitional Obsessions and Imperative Ideas.-A psychasthenic 
on going into a public building may count all the electric lights 
on the ceiling and the walls. In church, he may count the pipes 
in the Organ. On the street, he counts horses or telegraph poles. 
He has an imperative idea to count things. This condition is 
known as arithmania. 
Onomatomania.-This is the repetition of words and phrases. 
It differs from echolalia inasmuch as the words and phrases are 
not senseless. 
Pyromania.-This is a pathological desire to set things on fire. 
The symptom occurs also as a part of the syndrome of other 
diseases. 
Kleptomania.-The irresistible impulse to steal. This condi- 
tion often appears as a symptom of other psychoses, especially 
in paresis. 
Nymphomania.-The inordinate desire for and practice of 
sexual intercourse by women. This condition is also found in 
other psychoses. THE PSYCHONEUROSES AND NEUROSES 
205 
Satyriasis.-This is the same condition occurring in men. 
These pathological desires will be dealt with in the chapter on 
psychopathic personalities. 
Aboulia.-Loss or impaired condition of the will power. This 
condition may result from the presence of imperative ideas 
which prevent the patient from attempting to walk, stand, or 
perform other simple physical movements. The patient will lie 
in bed for months at a time, complaining that he is unable to get 
up. If fruit is put on a table before a patient, he may allow it 
to decay and state as a reason that he is unable to extend his 
hands to take the fruit. 
Astasia-Abasia.-The inability to walk, because of aboulic 
ideas, is a common symptom of hysteria. The obsessions and 
imperative ideas of psychasthenia exist with clear consciousness 
on the part of the patient. 
Diagnosis.-The diagnosis is quite easy in this class of cases 
The absence of dementia, the absence of delusions and halluci- 
nations, the clearness of consciousness and the non-dementing 
course of the disease make the diagnosis quite plain. The diag- 
nosis may be arrived at by a process of exclusion. 
Prognosis.-The disease is essentially chronic in character, 
by reason of the fact that it is built upon a condition of 
constitutional inferiority. The psychotic episodes incident to 
the obsessions pass when the patient yields to his morbid desires. 
The outlook for a permanent recovery is poor. 
Treatment.-Psychotherapy is of great value in this class of 
cases. The patient should be taught to use his defective capaci- 
ties in the very best manner possible. He should be encouraged 
to meet his morbid fears and desires in an intelligent manner, 
after the mechanism of their action is explained to him. A 
process of re-education should be attempted. Psychoanalysis is 
of benefit in this class of cases. The patient's physical condition 
should be carefully watched. The diet should be nutritious 206 
MANUAL OF PSYCHIATRY 
and easily digestible. The patient should secure eight hours 
of sleep and a moderate amount of exercise daily in some useful 
occupation. 
NEURASTHENIA 
Definition.-Neurasthenia is a functional psychosis charac- 
terized by marked symptoms of nerve exhaustion and fatigue, 
periods of hypochondriasis, a condition of abnormal susceptibil- 
ity to external stimuli, defective mental concentration, difficulty 
in thinking, irritability, and a wide variety of physical symptoms 
chiefly subjective in character. According to the character of 
the predominating symptoms, neurasthenia has been classified 
into the following types: 
1. Cerebral Type. 
2. Spinal Type. 
3. Gastro-Intestinal Type. 
4. Genital Type. 
5. Circulatory Type. 
Etiology.-The predisposition to this disease may be either 
inherited or acquired. It most frequently occurs between the 
ages of twenty and fifty years. Both sexes are affected to a like 
degree. It has been held by some authorities that there exists 
a condition of chronic auto-intoxication depending upon organic 
changes in the nervous system, due to exhaustion. Recently it 
has been held that neurasthenia is the result of insufficiency of 
the endocrene glands, especially the thyroid, adrenal and testicu- 
lar glands. The following exciting factors have been sufficient 
to precipitate neurasthenia: 
Mental Overwork. 
Physical Overwork. 
Sexual Excesses. 
Frequent Pregnancies. THE PSYCHONEUROSES AND NEUROSES 
207 
Severe Physical Shock. 
Mental Shock. 
Exhausting Diseases. 
Infectious Diseases. 
States of Autointoxication. 
Hemorrhage. 
Pathology.-No demonstrable pathology has been found in 
the nervous system. 
Symptomatology.-Cerebral Type.-In this form the patient 
is depressed. His face wears an anxious expression. He com- 
plains of persistent and intense headaches which are usually 
diffuse or occipital. A feeling of emptiness in the head is often 
noted. Often the patient feels as though there is a band about 
the head; that the head is held in a vise. The headaches are 
usually worse in the morning and pass off as the day grows 
older. The patient complains of an inability to perform mental 
labor of any sort. He has vague fears of impending evil; is 
afraid that he has some organic disease. Trifles irritate him. He 
is given to introspection and self-analysis. Insomnia is a com- 
mon symptom. The patient may sleep a few hours immediately 
on going to bed and remain awake during the middle portion of 
the night. The neurasthenic generally sleeps better in the morn- 
ing but he usually awakes with a headache. Sleep is disturbed 
by fearful and unpleasant dreams. Often the patients ap- 
preciate their conditions of irritability, their failure of memory 
and defective judgment and this insight into their condition ag- 
gravates the mental trouble, producing states of anxiety and 
depression. If the patient discovers a slight abrasion on the 
skin or has a fever blister he may feel certain that he has syphilis 
and may make the rounds of half a dozen doctors for advice, 
which he usually fails to heed. Occasionally patients attempt 
suicide because of their profound depressions. 208 
MANUAL OF PSYCHIATRY 
Spinal Type.-The symptoms of this variety are chiefly re- 
ferable to the spine. The patient complains of pain and points 
of tenderness along the spinal column; has sensations of weak- 
ness, complains of definite areas of hyperesthesia which may 
be located anywhere between the occiput and the sacral region; 
has formications and sensations of numbness in the limbs. There 
is a marked sense of prostration on physical labor. Sensations of 
stiffness in the back of the neck and lower portion of the head 
are frequently complained of in this type. 
Gastro-Intestinal Type.-The symptoms of this form include 
anorexia, coating of the tongue, gaseous distention of the stom- 
ach and a fluttering sensation in the abdomen. Constipation or 
diarrhoea are frequent. Gnawing sensations are noted, which 
are relieved by taking food. In order to overcome the discom- 
fort patients often try various diets and frequently so reduce 
their ration by eliminating those foods which they believe to 
be the cause of their trouble, that malnutrition results. Pa- 
tients of this type are users of patent medicines which are ad- 
vertised for the cure of "stomach trouble." Often they try 
fasting cures, indulge in eating raw foods, and follow all manner 
of dietetic fads. 
Genital Type.-The symptoms of this form are more common 
in the younger neurasthenics. They believe that some functional 
disorder of the genital system is responsible for their nervous 
and depressed condition. The males complain of seminal emis- 
sions or they become fearful that their sexual powers will be 
lost; they easily fall a prey to advertising quacks who "restore 
lost manhood." In spite of the patient's belief that he may have 
lost his sexual powers, he is often given to excessive sexual in- 
dulgence. The females suffer from pelvic pains and irregularity 
of the menstrual function. 
Circulatory Type.-The chief symptoms of the circulatory 
type are vague pains about the head, flushings of the blood to THE PSYCHONEUROSES AND NEUROSES 
209 
the head, palpitation of the heart, pounding of the blood ves- 
sels in the ears at night, pulsation of the abdominal aorta, hot 
and cold flashes over the body, dermatographia, coldness of the 
extremities, and cold, clammy skin. Occasionally there are 
marked dizzy spells attended by syncope. 
Course.-The disease as a rule is insidious in its onset, though 
it may develop rapidly after a shock, some infectious disease 
or pregnancy. The symptoms may be extreme or very mild. 
Some days the patient may feel very well, but this brief period 
of well-being may be followed by days of depression. Pa- 
tients as a rule feel worse in the morning and improve as the 
night comes on. Depending upon the nervous organization of 
the individual and his heredity and environment, the disease 
may run a short or protracted course. 
Diagnosis.-The diagnosis is usually easy, but great care 
must be taken to exclude all organic disease. For it must be 
borne in mind that neurasthenic states may accompany the or- 
ganic and essential psychoses. The diagnosis is to be made after 
a careful process of exclusion and searching physical diagnosis. 
Paresis.-Paresis is often attended by neurasthenic symptoms, 
but this disease is to be diagnosticated by the Wassermann re- 
action of the blood and spinal fluid and a careful neurological 
examination. The neurasthenic patient appreciates his mental 
defect very keenly, but the paretic as a rule does not. The 
paretic symptoms advance but the neurathenic symptoms sub- 
side or remain stationary. The paretic patient does not under- 
stand the seriousness of his trouble and has a tendency to under- 
estimate his symptoms while as a rule the neurasthenic exagger- 
ates his symptoms. 
Hysteria.-In this psychosis there are found restriction of the 
visual fields, globus hystericus, hysterical clavus, convulsive 
seizures and intense emotional states. 210 
MANUAL OF PSYCHIATRY 
Dementia Prcecox.-In dementia praecox there is as a rule 
marked emotional indifference, a progressive state of dementia 
and indifference to environment, and symptoms just the reverse 
of those found in neurasthenia. 
Brain Tumor.-Brain tumor is to be distinguished from neu- 
rasthenia by the focal signs and fundi examination. 
Manic Depressive Insanity.-Mild types of the depressive 
phase of manic depressive insanity often resemble neurasthenia, 
but in manic depressive insanity the condition of mental retarda- 
tion or increased psychomotor activity is prominent and there is 
a history of repeated attacks. 
Prognosis.-The prognosis as a rule is good but is depend- 
ent upon the patient's nervous organization, his heredity and 
his environment. If the conditions which operated to produce 
the state of nerve exhaustion can be corrected, a cure is quite 
likely. Recurrences are frequent. 
Treatment.-We generally find that the neurasthenic is a 
patient who has no definite philosophy of life. Faulty habits of 
mental activity are to be corrected. Worry, introspection and 
unproductive explosions of energy are to be transformed into 
special lines of useful activity. In addition to the patient's us- 
ual occupation some hobby or sport should be adopted to create 
new interests and thereby stop introspection and self-analysis. 
A definite programme of mental re-education is necessary. 
Life out of doors is desirable, with plenty of physical exercise 
for those who are strong enough to stand it. The poorly nour- 
ished and weak patient should be impressed with the fact that 
he is not suffering from an incurable disease and he should be 
given such mental suggestion as will assist him in maintaining 
a cheerful state of mind. The food should be nourishing and 
some digestive may be given after meals. The bowels and other 
emunctory organs should be kept active. 
Hydrotherapy is of great value in equalizing the circulation, THE PSYCHONEUROSES AND NEUROSES 
211 
thereby overcoming restlessness and nervousness. Hydrotherapy 
may be sufficient to produce sleep; if not, sedative drugs may 
occasionally be used provided great care is exercised to prevent 
the patient from becoming dependent upon the use of sedative 
medication. 
Drugs have no specific action in these cases, but tonics, as 
iron, quinine, strychnine or Blaud's pill with arsenic, may be 
given in cases where the patient is debilitated. Very recently 
glandular therapy has come into extensive use on the assump- 
tion that there exists a definite endocrene imbalance and that 
the glandular dysharmony can be corrected by the administra- 
tion of the various endocrene substances. The glowing clinical 
reports of reliable practitioners would indicate that this form 
of therapy should be tried in cases where there seem to be indica- 
tions for this type of treatment. 
Traumatic Neurasthenia.-This is a state of neurasthenia 
which occasionally follows railroad accidents, severe physical 
shock due to falls, or injuries in industrial plants. This type of 
neurasthenia is quite persistent. The patient becomes involved 
in litigation and mild delusions of persecution often occur in 
these cases. When the patient's suit has been definitely decided, 
either in his favor or against him, he usually recovers. 
ANXIETY OR DREAD NEUROSIS 
Definition.-The anxiety neuroses are a clinical group of 
chronic neuroses which are attended by a morbid state of anxiety 
and fear, associated with pronounced nervous and physical symp- 
toms, chief of which are tachycardia and irregularity of the 
heart's action, pseudo-angina, sensations of suffocation and dysp- 
nea, dizziness attended by difficulty of locomotion, attacks of 
trembling, profuse sweating, vomiting and diarrhoea. These 
symptoms seldom occur singly. The state of anxiety permeates 
the whole of consciousness and regulates conduct. 212 
MANUAL OF PSYCHIATRY 
Etiology.-This disease occurs in both sexes in about the 
same degree, usually between the twenty-fifth and forty-fifth 
year, though it may occur at any age. The majority of individ- 
uals who develop this disorder come from tainted stock, though 
it is possible to acquire a predisposition to this neurosis. The 
disease has been found to occur with great frequency in married 
persons and others whose sexual relations are not properly con- 
summated due to imperfect repression of sexual desires in the 
unmarried, conditions of sexual frigidity in the married, or those 
states of mind which interfere with the proper performance of 
sexual congress. Other factors, such as exhaustion from exces- 
sive exertion, continued insomnia or serious illness, may act as 
exciting causes. 
Pathology.-No definite pathology has been found in these 
cases. 
Symptomatology.-Patients who suffer from this disorder 
are generally irritable. Trifles annoy them excessively. They 
live in a constant state of fear and expectation. The fear is 
not from without but from within. They feel that they are likely 
to be visited by some incurable malady which will rob them of 
their physiological capacities. Often they worry about auto- 
matic acts, for they are afraid that they will lose the capacity for 
walking, standing or writing. Insomnia is a common symptom, 
especially after great mental exertion or periods of excitement. 
The patient interprets his feelings of weakness and lassitude to 
be the prodromals of an oncoming paralysis. Patients cross 
bridges before they come to them. Thinking about a duty that 
is to be performed in the distant future causes the patient to 
become highly irritable and nervous and to suffer from insomnia. 
In like manner headaches are produced. Patients are inclined 
many times to cease an active struggle for existence; are ready 
to quit their occupations for fear that they will fail at their work 
because of lack of ability to perform their duties. THE PSYCHONEUROSES AND NEUROSES 
213 
The physical symptoms are quite marked. The patient has 
sensations of stiffness of the joints throughout the body. He of- 
ten ceases to write because of a sensation of stiffness in the hand 
and swelling of the fingers. He has cramps in the legs and often 
in the throat; complains of difficulty in swallowing. Patients 
make the rounds of physicians and request frequent physical ex- 
aminations. They are given to excessive worry about every 
vague pain. Often they avoid going out into the open air on 
sunshiny days, for fear that the sunlight may hurt their eyes. 
They wear an excessive amount of clothing to avoid the inclem- 
ency of the weather. Often they will avoid walking for fear of 
falling down in attacks of dizziness. They often regulate their 
menus to prevent stomach trouble. At other times they have ex- 
cessive appetites. 
All the symptoms are attended by continuous states of anxiety 
and fear. Patients are oriented as to time, place and persons. 
There is no defect in the powers of intellection. Consciousness 
remains clear. There are no disturbances of conduct which in- 
terfere with the rights of others, and the patient fully appreciates 
the painfulness of his situation. 
Diagnosis.-Neurasthenia.-Patients do not present the 
symptoms of nervous exhaustion as in neurasthenia, and with 
the relief of the physical conditions which produce neurasthenia 
this disease disappears. Such is not the case in anxiety neurosis. 
Hysteria.-In this disease the stigmata of hysteria are present 
and the symptoms fluctuate from the sensory to the psychic and 
emotional fields. In the dread neurosis the symptoms are quite 
stable. 
Organic disease of the nervous system should be ruled out by 
careful examination. 
Prognosis.-Prognosis on the whole is not favorable. The 
disease is likely to become chronic and obdurate to treatment. 214 
MANUAL OF PSYCHIATRY 
Occasionally there are remissions and recoveries whether the pa- 
tient is treated or not. 
; Treatment.-A careful psychoanalytical search should be 
made. If there are sexual irregularities these should be corrected, 
if possible, by establishing a course of sexual hygiene for the 
patient. The patient should be encouraged and his mental ac- 
tivities should be diverted from himself and directed into useful 
employment. Careful attention should be paid to matters of 
physical hygiene. Insomnia should be controlled by daily warm 
baths and hot packs. Mild hypnotics, as veronal and sulfonal, 
may be employed when the insomnia is marked. Life in the 
open air and a moderate amount of exercise are beneficial. CHAPTER XIX 
PSYCHOSES WITH CONSTITUTIONAL 
INFERIORITY 
There is a group of personalities whose mental constitutions 
are so abnormal or anomalous that they find it difficult, because 
of their constitutional eccentricities, to adjust themselves to the 
usual conditions of society. Their deviations of conduct are 
chiefly in the emotional and volitional fields. They differ from 
the "queer" individuals whom we are accustomed to regard as 
normal, in degree only. Their defective mental makeup renders 
it impossible for them to view their environments in an average, 
normal way, and for this reason they very frequently develop 
psychotic episodes which lead to their commitment to institu- 
tions for the insane. The psychotic episodes which punctuate 
their lives from time to time are states of excessive nervousness, 
irritability and excitement; periods of confusion and of paranoid 
reaction. In this group of individuals we find the crank, the 
tramp, the criminal, the malingerer, the sexual pervert and the 
pathological liar and swindler. Under this general heading will 
be described the following types: 
States of Constitutional Depression 
States of Constitutional Excitement 
Sexual Anomalies 
Constitutional Immorality 
Malingering or Simulation. 
Etiology.-About seventy-five per cent of these individuals 
come of stock showing a neuropathic taint. 
215 216 
MANUAL OF PSYCHIATRY 
Pathology.-No demonstrable pathology has been found in 
the central nervous system of these individuals. Physically they 
present the anatomical and physiological stigmata of degeneracy. 
We often find malformations of the skull, asymmetry of the face, 
irregularities of the palate, malocclusion of the teeth, degener- 
ative types of ears, different colored irides, and disturbances of 
physiological functions. 
Symptomatology.-The chief states of psychopathic inferi- 
ority and the most prominent psychopathic personalities will be 
considered. 
Some of these individuals manifest states of extreme nervous- 
ness, which become specially apparent when they experience dif- 
ficulties of adjustment. They are particularly susceptible to 
the'misfortunes of life; unable to react in an adequate way to 
difficult situations. They are easily fatigued both mentally and 
physically; are inclined to take a pessimistic view of every un- 
pleasant situation. They cross bridges before they come to 
them; exhibit mercurial temperaments; are easily moved to tears 
or laughter; may show states of excessive sentimentality or in- 
humanity. They are subject to suggestion and their conduct 
is largely regulated by their whims and accidental impressions. 
Often they recognize the inadequacy of their reactions to the 
situations of life and vigorously attempt by the exercise of will 
power to overcome their deficiencies, but they are easily fatigued 
and enervated. In this state of fatigue they may be impulsive, 
irritable and lachrymose, and they often resort to the use of al- 
cohol or drugs to overcome the uncomfortable state of their feel- 
ings. They may be precocious sexually and given to the practice 
of masturbation in addition to normal sexual congress. Often 
they indulge in sexual sprees, which are followed by morbid 
states of repentance and sexual neurasthenia, attended by sexual 
impotence and spermatorrhoea. They have capricious appetites; 
often indulge in fasts which are terminated by gormandizing. PSYCHOSES WITH CONSTITUTIONAL INFERIORITY 
217 
They suffer from eructations of gas which may or may not be 
attended by vomiting. They suffer from insomnia, as a rule, 
and their sleep is disturbed by unpleasant and disgusting dreams. 
Under extremely distressing situations these patients often de- 
velop delusions of persecution and periods of confusion which 
are preceded by great restlessness and marked irritability. This 
condition of nervousness often resembles neurasthenia, but it is 
to be differentiated by the fact that the true neurasthenic re- 
covers under rest and symptomatic medication. In constitu- 
tional nervousness this is not the case, for the defect has its 
origin in a morbid nervous organization. Persons who exhibit 
the nervous temperament as a rule are not committed to insti- 
tutions for the insane, but they are constantly seeking relief at 
the hands of physicians or at institutions for rest cure, if they 
have the means to secure such treatment; otherwise they make 
themselves a burden in their homes and are looked upon as per- 
petual "grouches" and cranks. 
STATES OF CONSTITUTIONAL DEPRESSION 
Some individuals are so constituted as to be in a state of de- 
pression the greater part of the time. As a rule these individ- 
uals do not show any impairment of the mental powers. They 
are able to think in a logical, sequential manner, but every situa- 
tion in life is associated with a feeling of sadness and "the blues." 
They are very susceptible to suggestion of all sorts, especially to 
those of a depressing kind. They search in their past histories 
for troubles; fear that they have made some misstep which is 
likely to bring evil in the future. They are without self-con- 
fidence; have feelings of inadequacy; are fearful that they may 
become insane or that they may acquire some constitutional 
disease which will materially shorten their lives. This mental 
attitude leads to inadequate social adjustment. The individuals 
are afraid to assume the daily duties and burdens that come 218 
MANUAL OF PSYCHIATRY 
in their way. They do not use the powers they have to the full- 
est extent because of their morbid fears and dreads. They find 
it difficult to arrive at decisions in matters of any moment, 
though they do display the tendency to carry out little details 
with great exactness. If they are religiously inclined, much of 
their conversation is concerned with the future life and how to 
make preparations to meet it. They develop tics-twitching of 
the muscles of the face, shaking of the hand, turning of the head. 
This psychotic state is usually chronic. Shocks, whether they 
be emotional or physical, aggravate the patient's tendencies and 
inclinations. Occasionally patients do have remissions but they 
are usually temporary. Patients are often misunderstood by 
their friends, who accuse them of enjoying being sick. 
Treatment.-Patients should, so far as possible, lead a quiet, 
regular life, secure eight hours of sleep each day, and avoid all 
excesses. The food should be moderate in amount, and nourish- 
ing. If possible patients should have placed upon them small 
burdens and responsibilities calculated to employ their time and 
to lessen the opportunities for introspection and self-analysis. 
Symptomatic medication may be employed for constipation, in- 
somnia and nervousness. Physiotherapy is of value in these 
cases, chiefly because of the fact that it improves the circulation, 
increases the general nutrition and exerts a psychical influence. 
STATES OF CONSTITUTIONAL EXCITEMENT 
Among the anomalous conditions included under the term psy- 
chopathic inferiority are conditions in which the patients ex- 
hibit periodic episodes of excitement. At these times the pa- 
tients are talkative, egotistical, and the conversation is flighty 
and erratic. They find it difficult to adjust themselves to social 
conventions; indulge in all sorts of adventures; concoct plans 
and devise business schemes to acquire riches quickly; make 
foolish speculations on the market. When they are thwarted in PSYCHOSES WITH CONSTITUTIONAL INFERIORITY 
219 
their plans, which are always unstable and changing, they fre- 
quently exhibit outbreaks of temper and passion. They are also 
given to sexual excesses. These psychotic episodes are likely 
to be mistaken for an increase in psychomotor activity as seen 
in manic-depressive insanity or general paresis. The history of 
the case and the neurological examination usually make the diag- 
nosis clear. The course of this anomalous condition is essentially 
chronic. The apparent wealth of mental capacity and energy 
is dissipated in unproductive activities. They are ne'er do wells 
and failures in life. Occasionally some persons of this type pos- 
sess artistic abilities and appear to be brilliant, but they never 
reach the goal success. 
Treatment.-There is no adequate treatment of value in these 
cases. The excessive activity should be curbed and directed into 
useful channels, if possible. The patients should be so restrained 
as to prevent alcoholic and sexual excesses. Daily occupation 
at some useful endeavor not requiring a great deal of initiative 
or the exercise of judgment, is useful. Until the end of their 
lives these individuals remain a burden to their friends and a 
possible menace to the communities in which they live. 
IMPULSIVE STATES 
Frequently psychopaths exhibit periodic outbreaks of excite- 
ment, morbid tendencies, furores and frenzy. They feel impelled 
to do senseless and foolish acts, usually of a destructive nature. 
They turn in false fire alarms, wreck trains, commit assault and 
battery and occasionally kill, when acting under these impulses. 
These cases will be classified and will be described at greater 
length under the heading of constitutional immorality. 
Among the borderline and episodic states of mental alienation 
are to be found the anomalous conditions of the sexual instinct. 
SEXUAL ABNORMALITIES 220 
MANUAL OF PSYCHIATRY 
Not all persons having such anomalies are to be regarded as in- 
sane. The majority are poorly synthesized individuals of psy- 
chopathic constitution. As a rule they come of stock showing 
a neuropathic taint. 
Etiology.-Perverted sexual instincts are more frequently 
noted among males than among females. Sexual perversion was 
formerly thought to be a rare condition, but this is by no means 
the case. Sexual perverts of all types have been found in all 
classes of society, but particularly have they been observed 
among prison populations, in armies and navies, and in celibate 
institutions of learning. It is held by some authorities that sex- 
ual perversion is due to congenital defect. Other authorities of 
equal rank are inclined to ascribe environmental factors as caus- 
ative agencies for sexual perversion. 
These anomalous conditions of the sexual instinct may be 
divided into two groups; first, the quantitative anomalies, and 
second, the qualitative anomalies. 
Quantitative Anomalies.-There frequently occur in indi- 
viduals states of sexual frigidity or the lack of desire for sex- 
ual congress. This sexual anesthesia may often be a part of 
the symptom complex of hysteria, the result of sexual trauma, 
or possibly the result of ascetic religious ideas. In these in- 
stances it is more or less artificial. An opposite condition-sex- 
ual hyperesthesia, or eroticism-is often found in the psycho- 
pathic, in which the sexual desires are excessive and pathological. 
This condition may exist alone or it may be a part of the symp- 
tom complex of an essential insanity. In women this condition 
is known as nymphomania and in men as satyriasis. 
Qualitative Anomalies.-These anomalies are classified under 
two heads, perversions and inversions. Under the class of per- 
versions we have the following: 
Masturbation.-This practice, occurring in the transition peri- 
ods between infancy, early childhood and adolescence, probably PSYCHOSES WITH CONSTITUTIONAL INFERIORITY 
221 
has no pathological significance, but "serves to focalize the sex- 
ual sensations on the normal erogenous zones." Masturbation 
has often been thought to be the cause of insanity and for this 
reason the misnomer "masturbatic insanity" is found in some 
of the older texts on psychiatry. Masturbation is more often a 
symptom than the cause of a disordered mental state. 
Sadism-Active Algolagnia.-In this anomalous condition the 
sexual desire is gratified by the infliction of pain upon the sexual 
partner. This condition may be real or symbolic. It is more 
frequently found in the male, which is to be expected, as the 
male is usually the aggressor in sexual congress. 
Masochism-Passive Algolagnia.-In this anomalous condi- 
tion the sexual desire is gratified by suffering pain, either real 
or symbolic. This anomaly of the sexual instinct is more fre- 
quently found in women, probably for the reason that they usu- 
ally sustain the passive part in sexual congress. 
Homosexuality.-This is a condition of desire for actual sex- 
ual relations with an individual of the same sex. It is often met 
with in penal institutions and in hospitals for the insane. Oc- 
casionally it is found among tramps and among sailors and sol- 
diers, and it is not unheard of in celibate orders of the priesthood 
and in seminaries for females. Individuals suffering from this 
anomaly have a tendency to follow certain occupations. They 
are often met with among ladies' tailors, valets, waiters in res- 
taurants and hotels, window decorators and trimmers, and actors, 
particularly impersonators of the opposite sex. Kraftt-Ebing and 
Hall have recorded in medical literature instances in the various 
groups that have been discussed. White states, "Inversion con- 
sists of a lack of harmony between the physical and the psy- 
chical sex and leads to homosexuality or desire for persons of 
the same sex. Various physical anomalies are often found in 
these persons." For example, the general conformation of the 
body, pilosity, etc., may indicate one sex, while the genitalia are 222 
MANUAL OF PSYCHIATRY 
of the other. In the germ plasm there are present the male and 
female sex determiners and only one normally develops. Owing 
to some faulty development both the characteristics are partially 
involved and this mixture of sex characters may show itself in 
either the mental or physical organization or possibly in both. 
Up to a certain period in life, before the sexual instincts are 
developed in the child, he is, so far as mentality and inclina- 
tion are concerned, of neuter gender. But if the development is 
normal the sex development is proper for the physical sex of 
the child concerned. If this progress does not take place nor- 
mally he may remain undeveloped and in the infantile stage. As 
Freud puts it, he is polymorphous-perverse. 
Narcissism.-This is a type of perversion in which the individ- 
ual is in love with himself or his own body. It is a condition of 
auto-erotic sexuality. 
Fetichism.-This term is applied to that type of sexual per- 
version in which the individual is sexually excited and gratified 
by looking at, coming in contact with, or possessing some part 
of the body or clothing of another, such as the hand, foot or 
hair, or gloves, handkerchiefs or lingerie. It is not uncommon to 
find individuals of this type, if they are men, wearing articles of 
women's apparel. The reverse is true of the female sex. 
Bestiality.-This is a type of sexual perversion which shows 
itself in sexual relations with animals. Individuals given to this 
practice are to be found in practically every prison of any size. 
Exhibitionism.-This is a type of sexual gratification derived 
by exposing the genital organs. This condition rarely exists as 
an entity, but is usually a part of the symptom complex of an 
essential mental disorder. 
Necro'philia.-This term is applied to the desire for or the act- 
ual sexual congress with a dead body. 
General Symptomatology.-These conditions of inversion 
and perversion (anomalies) are very often expressions or a part PSYCHOSES WITH CONSTITUTIONAL INFERIORITY 
223 
of the symptom complex of the various insanities. White says 
of them the following: 
This list of anomalies of the sexual instinct as defined refers to the 
actual expression of this instinct in outward activity. All of these various 
manifestations, however, may appear in the phantasies of the patient, ex- 
pressed symbolically and without any appreciable tendency to carry them 
mto action. In fact, the analysis of practically any one would show a 
majority at least of these tendencies in symbolic expression in the un- 
conscious. It can easily be understood why this should be so, because 
such tendencies as homosexuality, narcissism, exhibitionism, etc., represent 
stages in normal development, the records of which are preserved in 
the unconscious. In their crude manifestations they belong to the symp- 
toms of mental defect, in their higher symbolic expressions in the neu- 
roses and psychoses they indicate the tendencies of the individual which 
have not been adequately socialized. 
The sexually perverted and inverted individual usually re- 
mains single, but a few marry with the view in mind to over- 
come their perverted sexual inclinations by the state of marriage. 
In some marriage is sufficient to overcome their inclinations, but 
this is not usual. The homosexual find partners of the same sex 
and indulge in so-called platonic friendship and sexual liaisons. 
In the majority of instances they do not show marked mental 
impairment, with the exception that they are easily fatigued by 
mental or physical labor. They are occasionally very much dis- 
tressed because of their perverseness and have an acute insight 
into the abnormality of their impulses. This makes them in 
some instances extremely sensitive, moody, introspective, and 
given to violent outbursts of temper. 
The male homosexual pervert as a rule gives great attention 
to his personal appearance, spends much time in adorning him- 
self, brushing his hair, using cosmetics and manicuring his fin- 
gernails. He is very fond of perfumes and wears flowers. It 
is observed that such persons enjoy doing sewing, arrange their 
rooms in the manner of a woman's boudoir, and wear many arti- 
cles of women's attire. We often find these individuals eunuchoid 
in their physical appearance, in some instances with high, fal- 224 
MANUAL OF PSYCHIATRY 
setto voices. The face is devoid of beard; they have delicate, soft 
skins. The hips may be excessively broad and the mammary 
glands greatly developed. 
The female invert usually presents many masculine traits of 
appearance. She may have a rough beard, a deep voice, hips 
smaller than usual, and chest and shoulders with the male type 
of development. She indulges in men's work, mannish clothes, 
and imitates men so far as possible in her mode of life. 
Diagnosis.-The diagnosis is usually easy. Sometimes the 
physical appearance and the general behavior of homosexual in- 
dividuals is such as to distinguish them from other individuals 
of the same sex. However, in many cases the diagnosis is to 
be made only upon the confession of the patient. 
Prognosis.-As this condition is dependent in the majority 
of cases upon a morbid basis, there is little hope for recovery. 
These persons may, however, learn from punishments in the way 
of incarceration in penal institutions, from social ostracism and 
from shame that it is necessary to control their inclinations and 
desires and to regulate their conduct by ordinary standards. In 
cases of acquired homosexuality the prognosis is somewhat more 
favorable if the individual can be placed in the proper environ- 
ment and given the necessary re-education. 
Treatment.-Hypnotism has been employed but it is of no 
more value than ordinary suggestion. The object of treatment 
is to reduce the excessive sexual excitability and to create in 
the individual an inclination for intercourse with persons of 
the opposite sex. The physical and nervous condition of the pa- 
tient should receive symptomatic treatment and medication. 
CONSTITUTIONAL IMMORALITY 
Definition.-The terms constitutional immorality, moral 
anaesthesia, moral insanity and moral imbecility have been used 
more or less indiscriminately to describe perverse states of the PSYCHOSES WITH CONSTITUTIONAL INFERIORITY 
225 
emotions, morbid dispositions, disorders of conduct and criminal 
behavior which were not apparently associated with definite 
states of mental aberration or enfeeblement. The idea that some 
individuals are immoral because of constitutional defects of the 
neural organism is repugnant to many persons, as it seems to 
challenge the traditional belief in man's free will. By some, 
every individual is presumed to be possessed of an innate moral 
sense or conscience which enables him to decide what is right 
and wrong in conduct and to act accordingly. Morality and 
character may be described as a function of the psyche, as is 
memory or imagination. The so-called moral sense or quality is, 
however, the last of the psychic functions to be developed, and 
is also the first to be confused, disoriented or destroyed by patho- 
logical processes affecting the mind. It is readily apparent that 
the function of intellection may be limited by developmental de- 
fects occurring in the physical evolution of the brain substance, 
and since this is the case there is no logical reason why moral 
capacities of the psyche should not suffer from defect for the 
same reason. Whether these conditions exist as clinical entities 
is still a mooted question. Much controversy has been waged 
pro and con. It is agreed by various authorities that there are 
individuals who seemingly cannot refrain from crime, because 
of their degenerate organizations which precipitate and impel 
them to immoral or illegal acts. Various definitions have been 
given to describe these anomalous states which lead to non-con- 
ventional behavior, and prominent among them are the fol- 
lowing: 
Constitutional immorality is recognized * * * ; in such instances the 
faults of character are out of proportion to the insignificant disorders of 
intelligence. (Tanzi) 
Moral imbecility is a condition of mental defectiveness which is shown 
by the absence of the highest functions, particularly the moral; capable 
of training to a considerable degree, but always a menace to society. 
(White) 
Disorders of the moral sentiments may be congenital * * *, an original 226 
MANUAL OF PSYCHIATRY 
deficiency analogous to that lack of musical sense or colorblindness which 
may coexist with a fair faculty of language and good contour perception 
* * * , with fairly good logical powers in the abstract. (Spitzka) 
The moral imbecile is a person who by reason of arrested development 
or disease of the brain, dating from birth or from early years, displays at 
an early age vicious or criminal propensities which are of an incorrigible 
and unusual nature, and are generally associated with some slight limita- 
tion of intellect. (Crichton-Browne) 
Etiology.-Heredity is the greatest factor operating to pro- 
duce this type of degeneracy. A history of insanity, epilepsy, 
feeblemindedness or other form of neuropathy, syphilis or alco- 
holism, is usually found in the antecedents. There is a high 
correlation between illegitimacy and moral imbecility. 
Symptomatology.-Outstanding types of constitutional im- 
morality have been noted, as follows: 
Born Criminals 
Pathological Liars 
Pathological Swindlers 
Mattoids or Querulants. 
Mechanism of Constitutional Immorality.-The processes of 
the mind are continuous and the so-called faculties or functions 
of the mind have no separate and distinct existence, but the 
terms of the old school psychology may be conveniently used in 
this chapter to designate those three great expressions of mental 
life-intellection, feeling and volition. These are conjoined and 
blended continually, and no one of the three can be taken into 
account without considering the other two. So in an endeavor 
to describe moral insanity it will be classified under three heads 
according to which one of the three functions of the psyche is 
most involved. We may therefore divide constitutional immor- 
ality or moral insanity into the following types: 
1. Where the defect of the psyche is most marked in the sphere 
of intellection. PSYCHOSES WITH CONSTITUTIONAL INFERIORITY 
227 
2. Where the defect is most pronounced in the emotional' 
sphere. 
3. Where the volitional sphere is chiefly involved. ' 
4. Where one or more or all the spheres of the mind are af- 
fected alike. 
It is the function of the mind continually to adjust the indi-> 
vidual to his ever changing environment, and a proper balance 
of the intellectual, emotional and volitional activities is neces- 
sary for this adjustment. In the constitutionally immoral we 
find a disequihbration of the above mentioned functions of men- 
tality which lead to the consummation of criminal acts or dis- 
ordered social behavior. The bank robber skillfully opens a 
vault with a most intricate lock, and secures its contents. The 
criminal's intellectual capacities were adequate to the under-f 
standing of the mechanism of the difficult lock, the necessary 
volitional activities were evidenced by its skillful manipulation1 
and the successful completion of his well calculated crime, but 
the much lowered or inert emotional capacities of his mental or- 
ganism failed to exert a proper moral inhibitory influence. Ac- 
tivity of the intellectual and volitional attributes of the psyche, 
disproportionate to those of the emotional qualities, resulted irr 
a decidedly abnormal reaction. This illustration seems, no 
doubt, to be extreme, yet it very adequately fits many cases of 
criminality. 
Immorality Due to Deject in the Intellectual Sphere.-There 
is a wide range in this form which extends from imbecility to; 
a condition of high-grade feeblemindedness. The individuals 
who belong to this class fail to see the relationship they bear to' 
other individuals, so far as moral or legal obligations are con- 
cerned. Crimes of this class are homicides, assaults, rapes and 
petty thefts. 
Immorality Due to Defect in the Volitional Sphere.-This' 
form is one of the most striking and interesting in the field of' 228 
MANUAL OF PSYCHIATRY 
morbid psychology. It is to be regretted that these individuals 
of defective will power are more studied and observed by the 
legal fraternity than by the medical. These persons are easily 
influenced. They know the difference between right and wrong 
and yet are unable to suppress or restrain their inclination to 
crime or anti-social conduct. They frequently experience ex- 
plosions of anger and at these times commit most atrocious and 
barbarous offenses against persons and property. The defects 
of the will may be arbitrarily classed under three heads: 
(a) The Explosive Will.-This condition is due to defective 
inhibition of the intellectual and emotional impulses which re- 
strain the activity of the volitional sphere. Persons of this mer- 
curial type with their hair-trigger temperaments are familiar to 
us all. In these individuals the motor impulse is translated 
into criminal acts before the defective mental mechanism can 
release the inhibitory social impulse. 
(t>) Exaggerated Impulses.-Criminal acts are committed in 
instances where the normal amount of inhibitory power is pres- 
ent, but is insufficient to overpower the pathological and exagger- 
ated impulses which lead to criminal acts. To this class of moral 
defectives belong the dipsomaniac, kleptomaniac and pyro- 
maniac. When these persons attempt to resist their impulses 
they experience such physical symptoms as prostration, tremor 
and vertigo, which disappear when the impulsive acts are per- 
formed. Unfortunate persons of this type are often aware of 
the morbidity of their behavior. 
(c) Arrest of the Will, or Aboulia.-This defect, we find, may 
be due either to an excess of inhibitory ideas or to a lack of 
sufficient volitional impulse to perform the duties demanded by 
society. In this condition the intellectual and emotional spheres 
are but little or in nowise affected, but the connecting link be- 
tween these two and the volitional sphere seems to be lacking. 
The crimes or misdemeanors resulting from this defect are sins of PSYCHOSES WITH CONSTITUTIONAL INFERIORITY 
229 
omission rather than commission. The lives of persons so af- 
flicted are classically described by Regis as being "one long con- 
tradiction between an apparent wealth of means and poverty of 
result." 
Immorality Due to Defect in the Emotional Sphere.-In this 
form the greatest defect of the psyche seems to be in the emo- 
tional sphere. The defect of the emotions may be divided into 
two varieties in one of which there is a condition of transient 
and ephemeral hyperactivity of such emotions as anger, hatred, 
jealousy and eroticism which leads to strocious and abhorrent 
acts of cruelty. In the second variety we find that the emo- 
tional defects are evidenced by a cold, heartless and indifferent 
attitude and a general paucity of ethical sentiments. We find 
in This class men of excellent education and others who, though 
not conventionally educated, are keen and cunning and possessed 
of an abundance of native intelligence. 
The Born Criminal.-Whatever type of mental mechanism the 
born criminal may show, in general he displays the following de- 
scribed traits: He is able to acquire, in a more or less compre- 
hensive manner and to varying degrees, a conventional educa- 
tion. His intellectual processes show no particular defect, but 
he entertains a decidedly myopic view of life. He is lacking 
in reflection and foresight. He is more intent on satisfying a 
momentary whim or passion than on looking to the future to 
see what difficulties his hastiness may cause him to encounter. 
He fails to show the usual amount of filial respect, is indifferent 
to family relations and unkind. The history shows that as a 
child he was given to the torturing of animals and the teasing 
and maltreating of playmates, sisters and brothers, and that in 
adolescence his conduct was such that it was necessary to send 
him to a reform school. He is supremely selfish and unable to 
resist temptation. He is irritable and vindictive. He may be a 
gangster, hobo, beggar, petty thief or larcenist. His acts ulti- 230 
MANUAL OF PSYCHIATRY 
mately lead him into penal institutions. He is usually con- 
stantly at war with society. After years of experience he be- 
comes the professional criminal. He represents the habitual 
criminal class to be found in penal institutions. 
■ Pathological Liars.-Individuals of this type are often men- 
tally alert and capable of acquiring a- conventional education, 
but their fund of information, while general, is usually super- 
ficial. Their information is not elaborated and coherent, their 
conceptions of life are based upon shortsighted and perverted 
views. They are given to misrepresentation and misconception, 
and have the faculty for mixing truth with fiction, which makes 
their statements at first appear plausible. They lie "for the joy 
of lying." They seem to derive pleasure from misrepresenta- 
tion. They tell lies when the truth would be of greater advan- 
tage to them. They lie so frequently that finally they believe 
their own lies or at least they are not able to discover the origin 
of their misrepresentations. Even though confronted with em- 
barrassing evidence that they have been detected in lying, they 
continue in the practice, inventing new fabrications to clear 
themselves from unpleasant consequences. These persons are 
often quite self-conscious. At times they show some remorse, 
but after making promises to reform they resort again to lies. 
Pathological Swindlers.-These persons form an interesting 
group. They take particular delight in cheating and swindling. 
They secure money from gullible and credulous persons by rep- 
resenting themselves to be members of rich families or relatives 
of prominent men, or posing as officers of the government. By 
these methods they issue fraudulent checks and letters. They 
live by their wits. Often they boast of their ability to swindle 
the public and regard themselves as benefactors saying that by 
swindling a credulous individual of his money they teach him 
a, lesson in thrift and economy and whet his foresight and acu- 
men. PSYCHOSES WITH CONSTITUTIONAL INFERIORITY 
231 
Mattoids and Querulants.-Individuals of this type usually do 
not show any mental defect and are able to acquire the conven- 
tional education. There is no defect in their processes of think- 
ing. Memory is not impaired. They are alert and keen but 
they show an exceeding sensitiveness of the emotional qualities 
of the mind. They are apprehensive and put paranoid inter- 
pretations upon trifling occurrences. They are always ready to 
combat with intensity what may appear to be the slightest in- 
fringements on their rights. At all times they distrust the mo- 
tives of others. They are revengeful and ready to secure redress 
of their fancied or real wrongs, employing the most vigorous 
means to obtain their ends. Egotism and self assertion are 
prominent characteristics of their mental attitude. They carry 
their quarrels, misunderstandings and fancied insults into the 
courts for settlement. They exhaust every opportunity for ap- 
peal from decisions if judgments are rendered against them. Oc- 
casionally their hotheaded tendencies and dispositions cause 
them to commit crimes against the person. Because of their ex- 
treme sensitiveness and belligerent behavior they usually fail 
to make a success of whatever pursuits they may follow in life, 
and their failures they charge to their enemies. 
Diagnosis.-The diagnosis of constitutional immorality is by 
no means easy or even always possible. A very careful investi- 
gation and consideration of the individual's full life history in 
longitudinal and cross section is absolutely necessary. The in- 
dividual's life must be reviewed from infancy and full weight 
must be given to the influence of environment, education and 
standards of living and the character of the reactions to them. 
Moral insanity is to be distinguished from the essential insan- 
ities which have crimes and misdemeanors as a part of their 
symptom complex. Epilepsy, dementia praecox, paresis, manic 
depressive insanity, feeblemindedness and other types of essen- 
tial psychoses must be carefully ruled out. The mattoids are 232 
MANUAL OF PSYCHIATRY 
to be distinguished from paranoiacs by the fact that the paranoi- 
acs evolve carefully systematized delusions to defend their par- 
ticular claims. Genuine delusions are not exhibited by the mat- 
toids. After the pseudoquerulant or mattoid has exhausted his 
means of redress in the courts, he does not resort to desperate 
measures to secure his ends, but makes an attempt to forget 
his difficulties and troubles. The paranoiac passes through 
the stage of suspicion, persecution and transformation of the 
personality, which is not the case with the mattoids. The mental 
deviations of the mattoids do not follow a definite line of prog- 
ress. 
Treatment.-There is no satisfactory treatment of the born 
criminal. His behavior leads him into prison, where he is kept 
for indefinite periods, spending most of his life there. Very 
rarely individuals of this type, if taken in hand while very young 
and placed in a favorable environment and under effective re- 
straints and compelled to lead quiet, regular lives, manage to 
be self-supporting, law-abiding citizens in a negative sort of 
way. Craniectomy has been tried in the treatment of delinquent 
children, but the results are not at all gratifying. For the bene- 
fit of posterity, sterilization is advocated. Lugaro has suggested 
that the impulsive criminal have his thyroid gland mutilated, 
care being exercised that the parathyroids are not injured, with 
a view to bringing about a mild degree of intoxication not un- 
like that found in myxedema, which would calm and allay irri- 
table and impulsive tendencies without impairing the intellectual 
capacity. We must seek to detect abnormalities in the children, 
and, should we find deviations toward criminal tendencies, we 
should place them in a healthful environment and give them such 
schooling as will particularly develop their social instincts and 
tend to compensate for their inherent defects. The prognosis, 
however, is bad, for no amount of training will alter or long 
hide the vices of organization. There is no satisfactory treat- PSYCHOSES WITH CONSTITUTIONAL INFERIORITY 
233 
ment for the pathological liar or swindler. Their acts ultimately 
lead to incarceration, and for long periods at least society is pro- 
tected from them. There is no specific treatment for the mat- 
toids. Occasionally temporary confinement in hospitals for the 
insane and private institutions for the mentally defective are 
of advantage. Restraint imposed upon them by intelligent, phil- 
anthropic persons is found to be of service. By these means 
some of their energy is directed into channels that are useful, 
instead of being entirely lost in fruitless endeavors. 
MALINGERING 
Malingering is the deliberate feigning of mental and physical 
symptoms of illness with the intention to deceive. Self inflicted 
injuries and mutilations of the body, when done to escape an un- 
pleasant or difficult situation, are to be considered under the 
head of simulation. Malingering is practiced by criminals in 
penal institutions with the view in mind to escape work allotted 
to them, to secure a change of occupation, to visit the prison 
hospital, to secure transfers from prison to insane hospitals where 
the chances for escape are better and where life is less active and 
is devoid of strict discipline. In the non-criminal classes ma- 
lingering of insanity is practiced for the purpose of avoiding mili- 
tary service, to escape from unhappy matrimonial ties, to pre- 
vent divorce proceedings and the settlement of estates, to arouse 
sympathy, to avoid legal responsibilities, to secure industrial 
compensation, and for other reasons of similar nature. 
A prisoner usually attempts to imitate acute maniacal states. 
He assumes a state of apparent excitement, is restless and talk- 
ative, yells and screams, tears his clothing, makes wild gestures, 
and keeps up a constant rehearsal of silly, extravagant behavior 
when he believes he is under observation. The symptoms sub- 
side when the patient thinks he is not watched. 
The condition of dementia is probably the next most fre- 234 
MANUAL OF PSYCHIATRY 
quently essayed. The prisoner pretends to be disoriented, stu- 
pid, forgetful, childish in his manner and silly and puerile in 
his judgments. He disregards the rules of the institution with 
apparent indifference to the consequences. 
Melancholic states are often attempted, but this is probably 
the least successful attempt that the malingerer can make, for 
remorse, introspection, self-analysis, sorrow and self-accusation 
are rarely seen in penal institutions. When a melancholic form 
of insanity is attempted the prisoner generally pretends to be 
in a stupor or a state of irresponsiveness, indifferent to his en- 
vironment and neglectful of the calls of nature. 
Some of these simulated cases of insanity are so well done that 
the untrained observer is often deceived. The alienist usually 
finds that the malingerer overdoes his part, for he generally en- 
tertains the idea that the insane are always absurd in their ac- 
tions, manner and conversation. His replies to questions are 
made with such studied silliness, absurdity and systematic reg- 
ularity that the careful examiner at once becomes suspicious. 
The malingerer seeks to impress the observer with the idea of 
insanity, whereas the real lunatic, if he has any insight into 
his condition, generally does the reverse. In one instance a ma- 
lingerer who came under the notice of the author put his food 
in his shoes and his shoes in his pocket, and emphatically in- 
sisted that such behavior was indicative of insanity. Simula- 
tions of insanity while presenting some of the symptoms which 
belong to the form that is copied, are incomplete, or else addi- 
tional inconsistent symptoms may be added. The symptoms of 
a terminal dementia would make an extremely poor combination 
with those of the manic phase or those of manic-depressive in- 
sanity, yet the feigner often attempts this combination. 
Relatively speaking, few persons succeed in deceiving phy- 
sicians who are familiar with mental disease. It is a difficult 
thing to portray accurately the symptoms of insanity, at least PSYCHOSES WITH CONSTITUTIONAL INFERIORITY 
235 
for any length of time, and many of the evidences of insanity 
cannot be simulated. The alienist, recognizing the difficulties 
he may encounter, must be exceedingly slow and careful in 
making tests. A searching inquiry must be made into the family 
and personal history, and here he must be exceedingly careful, 
for the information may be biased, prejudiced and untrust- 
worthy. 
In states where the seemingly insane prisoner is transferred 
to civil hospitals for the insane, the playing of the "crazy game" 
is quite prevalent, but in states where insane prisoners are trans- 
ferred to hospitals for insane criminals, these hospitals being 
especially constructed and especially administered to prevent 
escapes, the "insanity dodge" is becoming very much less popu- 
lar. 
Epilepsy is often feigned. The simulator falls in a comfortable 
spot. His body is convulsed and twisted as he attempts to per- 
form the movements of the grand mal seizure, and he froths at 
the mouth-with the assistance of a little soap. His tongue 
is never bitten. A careful inspection of the patient and a dash 
of cold water or a spray of ether or chloroform is usually suffi- 
cient to reveal the fraudulent character of his convulsions. The 
use of soap, however, is not restricted to the simulation of epi- 
lepsy, for often it is taken in the form of pills to produce intes- 
tinal trouble. The simulator frequently succeeds in producing 
a most intractable mucous diarrhoea. Various other substances 
are used for the same purpose, the most common being tooth 
paste, tooth powder, tobacco juice, wood alcohol, lime water, 
antiseptic solutions and turpentine. One malingerer who came 
under the observation of the writer produced phosphorus poison- 
ing with its attendant symptoms by eating matches. Another, 
to avoid certain tasks and to show his displeasure concerning 
institutional rules, swallowed parts of his mirror, the face of his 
clock, and the electric light globe from his cell. Each time glass 236 
MANUAL OF PSYCHIATRY 
was recovered from this human ostrich in the usual manner, 
without apparent harm to him. Psychopathic prisoners occa- 
sionally amputate fingers and mutilate the body. In one in- 
stance a convict made the request that he be taken out of the 
institutional butcher shop. When he was informed that his wish 
could not be granted he became very irritable and on his return 
to work chopped off several fingers with a cleaver. To show 
his displeasure another prisoner sawed off his fingers with a buzz 
saw. To escape work, prisoners often burn themselves with fire, 
alkalies and acids, or they will apply small poultices of lime 
to the body long enough to bring about inflammation. After 
several applications of these poultices, discharging ulcers are 
produced which render the prisoner unable to do his work. 
Prisoners often produce swelling of the limbs by drawing a sock 
or wet cloth over a limb and then pounding it until it is red 
and swollen. This method produces little external evidence of 
the manner in which the trauma was produced. 
Feigning blindness is not a rare practice, but the usual tests 
for blindness are sufficient to discover this subterfuge. It is 
well known among some of the criminal fraternity that instilla- 
tion of atropin solution into the eyes will produce defects of 
vision and even temporary blindness. 
Prisoners have produced the oral symptoms of septic sore 
throat by long-continued sucking of brass, which produces 
grayish-white ulcers in the mouth and throat. Belladonna has 
been employed to produce a dryness of the throat and redness 
of the skin, belladonna plasters being boiled to obtain the drug. 
Frequently the simulator picks the gums with some sharp 
instrument to produce bleeding, to simulate hemorrhage from 
the stomach and lungs. Occasionally prisoners have introduced 
pieces of wire into the urethra to induce hemorrhage. 
The manner of producing these deceptions and the methods PSYCHOSES WITH CONSTITUTIONAL INFERIORITY 
237 
employed are as numerous as the circumstances and the ingenu- 
ity and the means at hand permit. 
The malingerer is generally a psychopath who resorts to 
simulation and produces physical symptoms and disabilities to 
enable him to escape unpleasant or painful situations in which 
he finds himself. Approximately 75 per cent of all malingerers 
are individuals who show mental instability and psychopathic 
tendencies. Malingering is sometimes a part of the symptom 
complex of some of the essential insanities. The hysteric may 
aggravate his symptoms by simulation. The epileptic learns to 
feign convulsive attacks. Hysterical paralysis due to cortical 
disassociation is, however, not to be regarded as simulation if 
the patient is suddenly made to walk by putting him in a state 
of fear. The question in this case is not whether the paralysis 
is of an organic or functional nature, but whether the patient 
pretended his symptoms with the intention to deceive. 
Persons who find it necessary to practice malingering in order 
to meet an unpleasant or difficult situation are usually of a 
psychopathic makeup. Their reasoning powers and judgment 
are poor, for they fail to perceive and take into account that 
their lies and deceptions will soon be discovered. Malingering 
is a process of reversion to an infantile method of adjustment. CHAPTER XX 
PYSCHOSES WITH MENTAL DEFICIENCY 
IDIOCY, IMBECILITY AND FEEBLEMINDEDNESS 
The mentally deficient frequently develop psychotic states 
chief of which are episodes of confusion, irritability, intense 
anger or excitement, paranoid states, periods of depression and 
stupor and states of hallucinosis. Occasionally they may have 
engrafted upon their state of mental enfeeblement conditions of 
dementia praecox and manic depressive insanity. 
Definition.-These conditions of mental defect may be clini- 
cally subdivided according to the character of their symptoms, 
or they may be classified psychologically according to the mental 
level as determined by psychometric tests. Both classifications 
will be given. The American Association for the Study of the 
Feebleminded has formed the following definitions on a psycho- 
logical basis relating to the classes of mental defect: 
Idiot.-A person having a mental level of two years or below. 
Imbecile.-A person having a mental level of from two to 
seven years. 
Moron.-A person having a mental level exceeding that of 
an imbecile, ranging between seven and twelve years. 
Subnormal.-A person having a mental level slightly above 
twelve years but below average adult level. A distinct patho- 
logical borderline is impossible to draw in this type of mental 
defectiveness. 
Classed according to clinical methods, the various degrees have 
been described as follows: 
Idiocy.-This is a condition of extreme mental defect due to 
arrested cerebral development, either in utero or in early life. 
238 PSYCHOSES WITH MENTAL DEFICIENCY 
239 
Idiots as a rule are not teachable. However, they may infre- 
quently be taught to attend to the calls of nature. 
Imbecility.-A condition of profound mental defect, either 
congenital or acquired. Imbeciles are teachable and they can 
acquire a slight amount of knowledge, but not sufficient to enable 
them to care for themselves or to be other than a menace to 
society when not under restraint. 
Feeblemindedness.-A condition of slight mental defectiveness 
existing from birth or from an early age, by reason of which the 
individual is incapable of managing himself or his affairs with 
ordinary prudence or competing on equal terms with his fellows. 
States of feeblemindedness are to be distinguished from con- 
ditions of dementia. The mentally defective have always lacked 
in mental capacity, whereas the demented individual has been 
reduced to a low psychological level by reason of deteriorating 
mental disease. The classical distinction made by Esquirol is 
apropos: "The demented man is deprived of the good that he 
formerly enjoyed; he is a rich man become poor; the idiot has 
always lived in misfortune and poverty." 
Etiology.-Heredity is the most potent factor in the produc- 
tion of mental defectiveness. There is found in 70 per cent of 
all cases some hereditary taint such as feeblemindedness, epi- 
lepsy, hysteria and other forms of the essential psychoses, organic 
disease of the brain, syphilis or tuberculosis. Alcoholism is an 
important factor. Drunkenness in one or both parents at the 
time of conception is a potent cause of feeblemindedness. Con- 
sanguinity is a fruitful source of feeblemindedness, as has been 
shown by the careful study of family histories, by reason of the 
fact that the offspring often receives a double inheritance of 
mental defect. Contrary to the popular belief, consanguinity 
in parents who are free from hereditary taint does not result in 
the production of mentally defective offspring. Other causes 
exogenous in nature include trauma to the brain or spinal cord, 240 
MANUAL OF PSYCHIATRY 
neural lesions from meningitis, scarlet fever and prenatal con- 
ditions such as uterine exhaustion and emotional stress during 
pregnancy. Statistics show that during times of war and siege 
many mentally defective children are born. The causes of 
mental defectiveness may be classified into three groups, depend- 
ing upon the time of their operation: 
Causes operating before birth: 
1. Hereditary mental weakness in parents. 
2. Neurotic disease in parents. 
3. Syphilis in parents. 
4. Consanguinity in mentally defective parents. 
5. Drunkenness in parents. 
6. Maternal ill-health. 
7. Shock to the mother during pregnancy. 
8. Exhaustion during pregnancy. 
Causes operating at time of birth: 
1. Prolonged labor. 
2. Protracted pressure of head in birth canal. 
3. Forceps delivery. 
Causes operating after birth: 
1. Convulsions. 
2. Infantile paralysis. 
3. Traumatism. 
4. Severe febrile diseases. 
Pathology 
Gross Pathology 
Microscopic Pathology 
1. Embryonic development of the 
nerve cells. 
2. Reduction of the nerve cells. 
3. Absence of the nerve cells. 
4. Increase in the neuroglia. 
5. Absence of the stratification of 
nerve cells in the cortex. 
(Similar changes in the spinal 
nerve cells.) 
1. Hypertrophy of the brain, gen- 
eral or local. 
2. Atrophy of the brain, general 
or local. 
3. Malformation of the brain: 
Asymmetry of the lobes 
Asymmetry of the convolu- 
tions 
Microgyria 
Macrogyria. PSYCHOSES WITH MENTAL DEFICIENCY 
241 
4. Absence of the corpus callosum. 
5. Hydrocephalus. 
6. Porencephalus. 
7. Tumors. 
8. Thickening of the cerebral ar- 
teries. 
9. Cysts of the cerebellum. 
10. Tuberous hypertrophic sclerosis. 
11. Focal softenings. 
12. Meningitis. 
13. Chronic myelitis. 
Symptomatology of Idiocy.-The symptoms of idiocy will 
be described under the chief clinical types. 
The absence of any mental life is the chief symptom of idiocy. 
Idiots are incapable of education, absolutely helpless, and lead 
a purely vegetative existence, simply sleeping and eating, except 
at times when they cry or make inarticulate sounds and senseless 
movements. 
Physical Symptoms.-In the physical sphere we find all 
manner of stigmata, anomalies and developmental defects. The 
skull is subject to all manner of malformations. The idiot's head 
is usually of the microcephalic type, though macrocephalic heads 
are found. The physiognomy is usually distorted and out of 
proportion to the size of the head. Anomalies of the oral cavity 
are frequent; the palate is usually exceedingly high and sharply 
arched, or it may be very broad, flat and irregular, and is often 
deft. Hutchinsonian teeth are frequently observed. Tics, chorei- 
form and athetoid movements and drooling of the saliva are 
characteristic. Paraplegia and hemiplegia are often seen, and 
a marked disorder of the capillary circulation is noted. The skin 
is usually harsh, dry and anesthetic, though ulcerations are often 
found in the lower limbs and feet. The hair is mangy and 
coarse; the genital organs are usually imperfectly developed; 
complete absence of the testicles is frequently found, due to the 
fact that they are undescended or atrophied. Hydrocephalus 
16 242 
MANUAL OF PSYCHIATRY 
is frequently observed in idiocy. In this condition there is 
destruction of the cortical cells and obliteration of the motor 
tracks in the brain due to pressure. The head is enormously 
large and out of all proportion to the rest of the body and the 
patient is usually unable to lift his head off his pillow. The 
enormously dilated ventricles are filled with an excess of cerebro- 
spinal fluid and the brain is virtually a sac of water. Death 
usually occurs early in cases of this type, but there are excep- 
tions to the rule. 
Microcephalic Idiocy.-Here we find an extremely small head, 
frequently of a circumference of less than seventeen inches. 
There seems to be an excessive development of the face and 
jaw, but this is more apparent than real. 
Amaurotic Family Idiocy.-This form of idiocy was first 
described by Dr. Sachs. It has been found only in Jewish chil- 
dren and it develops about three months after brith. The chief 
symptoms are blindness, weakness of the body muscles succeeded 
by spacticity and rigidity, retraction of the head, emaciation, 
and absence of mental life. Death usually occurs within two 
years. 
Thyroigenous Idiocy.-This is a state of idiocy in which the 
characteristic symptoms of cretinism and myxedema are present. 
Epileptic Idiocy.-This is the association of epilepsy with 
idiocy, and epilepsy stands in a causal relationship to this group. 
Paralytic Idiocy.-This type of idiocy is attended by mono- 
plegia, hemiplegia or diaplegia, which occur as a result of the 
lack of cerebral development. Cysts are often found in this 
condition, of the true type of porencephalus, in which there is a 
cyst directly connected with the ventricles, or false porencepha- 
lus, where a cystic condition has been formed within the brain 
substance as a result of inflammatory conditions or necrotic 
softenings. The type of paralysis depends upon the location of 
the cysts. PSYCHOSES WITH MENTAL DEFICIENCY 
243 
Traumatic Idiocy.-This is a state of idiocy dependent upon 
trauma sustained to the head as the result of forceps delivery 
or pressure upon the cranium in the birth canal. 
Inflammatory Idiocy.-This is the type of idiocy which fol- 
lows states of meningitis which may occur in any of the 
infectious or febrile diseases. The meninges may be involved 
alone, but as a rule the brain substance shares in the same 
process of inflammation. The physical symptoms vary with the 
intensity and the location of the meningitic process. 
Sclerotic Idiocy .-We find at post mortem, in this type of 
idiocy, sclerotic conditions of the brain substance, and in these 
sclerosed parts of the brain the cells are reduced in number or 
are altogether absent. The brain is often increased in weight 
in this type and is of a very solid consistency. The other organs 
of the body share in the same process. Tumors of the kidney 
and other internal organs are found. Adenoma and sebaceum 
are also frequent. 
Syphilitic Idiocy.-This form of idiocy is due to inherited or 
congenital syphilis, the marks of which are evident in the 
Hutchinsonian teeth, radiating scars about the corners of the 
mouth and lips, inflammation of the nares, and interstitial 
keratitis. About 20 per cent of the patients who show these 
symptoms give a positive Wassermann of the blood and spinal 
fluid. 
Sensorial Idiocy.-This state of extreme mental defect is 
dependent upon the deprivation of two or more of the senses, 
particularly the senses of sight and hearing. 
Mongolian Idiocy.-This term is applied because of the 
fancied resemblance of the patient to the Mongolian type. The 
face is broad, the nose flat, the cheek bones high and the eyes 
almond-shaped and slanting. The skull is short from the fore- 
head backwards, but there is an apparent increase in the width 
of the skull. The forehead does not recede, but on the contrary 244 
MANUAL OF PSYCHIATRY 
is quite prominent. The hands resemble those of the cretin 
somewhat. They are broad and the fingers are short. 
Symptomatology of Imbecility.-Mental Symptoms.-Pro- 
nounced Type.-Imbeciles are capable of acquiring a slight 
degree of education. They learn to walk, talk, attend to the 
calls of nature, and recognize letters and figures. Their powers 
of perception and comprehension are very limited, however. 
They perceive but little within their environment and profit little 
by experience. They have no insight into their condition, are 
exceedingly egotistical, have no regard for the rights of others. 
The memory is faulty for the most simple occurrences. They 
are exceedingly gluttonous in their habits, are irritable, irascible, 
given to the practice of masturbation, and often attempt to 
commit rape. They are petty thieves, make dangerous assaults 
and occasionally commit homicide. 
Milder Type.-Patients of this type are able to learn to read 
and write, to add, subtract and multiply in simple numbers, 
acquire a few dates about history and learn some of the simpler 
elements of grammar, but the height of their mental development 
is very soon reached. They are often refractory and show 
symptoms of brutality and cruelty; they torture animals, cripple 
birds, laugh at the pain of their fellows, and seem to delight 
to inflict suffering upon others. Psychotic episodes are particu- 
larly common in this type of the mentally defective and they 
are prone to develop dementia preecox and paranoid states. 
Savant Imbecility.-This is a condition of general mental 
defect such as has just been described, which has associated with 
it an anomaly shown by a greater or less ability to excel in some 
particular sphere, such as music, memory or mathematics. The 
well-known "Blind Tom" belonged to this class. He exhibited 
remarkable musical ability, which stood out in marked contrast 
to profound mental defect. 
Imbeciles are frequently well formed and quite healthy. As PSYCHOSES WITH MENTAL DEFICIENCY 
245 
a rule, however, the skull shows malformations and the physi- 
ognomy denotes the mental defect. A cleft palate and uvula 
and degenerate ears are found in many cases. The sexual organs 
are often rudimentary, although they are occasionally found to 
be excessively large. 
Symptomatology of Feeblemindedness.-Individuals of 
this type often appear on casual examination to be normal. They 
impose upon the credulity of those who do not understand them. 
Superficially they may appear quite bright. They are exceed- 
ingly egotistical. Often they are very talkative and seek to 
impress others by a show in dress, and in conversation by the 
use of high-sounding phrases. They have an exaggerated sense 
of their own importance. They show a lack of power to make 
the necessary social adjustments. They are very apt to be anti- 
social in their conduct, and exhibit marked lack of foresight of 
the consequences of their acts. They show a decided inability to 
manage their affairs; cannot be self-supporting; often are crimi- 
nals. The majority of the public prostitutes belong to this type. 
They are particularly susceptible to the development of acute 
psychoses. 
The high-grade types of feeblemindedness are readily detected 
by the use of the Binet-Simon scale of intelligence test, described 
in Chapter XXIII. This is a graded series of tests requiring the 
exercise of intelligence. The tests call for the solution of various 
problems, such as arranging a series of small blocks of equal 
size in order of weight, repeating numbers, detecting the absurd- 
ity of statements, reproducing simple designs from memory after 
ten seconds' exposure, arranging blocks in a construction puzzle, 
repeating sentences of different lengths, putting together dis- 
arranged sentences, making sentences from given words, marking 
out the path which would be followed in finding a lost ball in 
a circular field, interpreting fables and proverbs, etc. These 
tests involve reason, memory, imagery, discrimination, associa- 246 
MANUAL OF PSYCHIATRY 
tion, comparison of ideas, ingenuity, judgment, and, in short, 
practically all the mental functions which may be considered 
as making up the general level of intelligence. 
Diagnosis.-The simple types of mental defectiveness are 
readily diagnosed, but great care must be exercised in differ- 
entiating states of dementia from conditions of imbecility and 
feeblemindedness. The higher types of feeblemindedness are 
sometimes difficult to distinguish from dementia praecox. In 
dementia praecox the patients may improve, which is never the 
case in feeblemindedness. It must be remembered, however, that 
the feebleminded often develop dementia praecox. 
Juvenile Paresis.-This condition is to be ruled out by the his- 
tory of the case, the Wassermann reaction of the blood and 
spinal fluid, and the neurological examination. 
When the individual is more than 25 per cent retarded for his 
psychological age, he is to be regarded as feebleminded. How- 
ever, any adult whose mental age is less than twelve years may 
prove to be distinctly feebleminded if the social reactions indi- 
cate a weakening of the inhibitions and the inability of the 
individual to adjust himself to society. 
Prognosis.-The prognosis is unfavorable. No change in the 
mental status of the mentally defective individual can be made. 
The majority of idiots die at a very early age. The higher types 
may, by intensive training in proper schools and institutions, 
acquire the ability to become self-supporting under the direction 
of others. The general conduct of the feebleminded may be 
improved by teaching the defectives to use their limited powers, 
but there is no real increase in their mental capacities. 
Treatment.-The mental defectives should receive all neces- 
sary medical and surgical care. Surgical conditions which re- 
flexly produce irritation, such as adenoids and diseased tonsils, 
phimosis, undescended testes, hernia and carious teeth, are to 
be corrected. Great improvement is often noted, particularly PSYCHOSES WITH MENTAL DEFICIENCY 
247 
in deportment, after these pathological conditions have been 
remedied. 
Cranial decompression has often been tried but in the expe- 
rience of the writer no real benefits have been observed. Even 
though real and apparent pressure has been relieved, the defec- 
tive nerve structure remains unchanged. 
Cases in which lues has played a definite part occasionally 
show improvement after intensive treatment, but on the whole 
the effects of antiluetic treatment are disappointing, for the 
structural damage has been completed, as a rule, before the 
treatment can be given. However, further degeneration of the 
nervous tissue may be prevented. 
Individuals who are mentally retarded and physically defec- 
tive because of disturbance of the endocrene glands or metabolic 
malfunction, may frequently be mildly benefited by the use of 
glandular therapy. Institutional care is indicated in the major- 
ity of instances, especially where the family is not in a financial 
position to care for the defective individual, as he is likely to 
become anti-social. CHAPTER XXI 
DIAGNOSTIC GROUPINGS OF THE SYMPTOMS OF 
THE PSYCHOSES 
The general symptoms of the psychoses are so varied, so com- 
plex, and so closely related, that they are confusing, and as a 
result of this state of affairs, the practitioner finds it somewhat 
difficult to classify and recognize the symptoms which he may 
encounter in the study of his patient and is content with merely 
labelling the patient as insane. This incomplete diagnosis is 
of no particular value, for the friends and relatives of the patient 
are already certain that the patient is abnormal before the physi- 
cian is consulted. They look to the physician to supply them 
with an accurate diagnosis, for with the correct diagnosis comes 
the information they wish to have namely, the nature of the 
psychosis, its duration and prognosis. 
While the symptoms are described in detail in the chapters 
dealing with the various psychoses, the general symptoms will 
be arranged and grouped in the following order so as to point 
out to the student and practitioner the ear-marks of the most 
important psychoses, thereby saving time and supplying a diag- 
nostic key to a working knowledge of psychiatry. 
DEMENTIA AND ALLIED PSYCHOSES 
This type of disorder usually makes its appearance at the 
time of puberty or adolescence, and for this reason it has been 
called, as the name implies, the insanity of youth. Occasionally 
it may develop after twenty-five or thirty years of age. It is 
attended by mental deterioration, which varies from a slight 
248 DIAGNOSTIC GROUPINGS OF SYMPTOMS OF PSYCHOSES 
249 
degree of intensity to one of profound defect. The following 
diagnostic symptoms are common to all types of this disorder. 
1. Onset.-The manner of onset is usually insidious, though 
occasionally it may appear to be very rapid. Close observation 
usually reveals that it is slow, even in the types where the onset 
is apparently sudden. 
2. Consciousness is usually clear, except in states of excitement 
or stupor. 
3. Orientation.-There is no disorder of orientation as a rule, 
except when some delusions exist concerning time, place and 
person. 
4. Hallucinations.-These are common and are visual, auditory 
and somatic in form. 
5. Delusions.-Delusions are very frequent, quite absurd and 
foolish; they are not systematized. 
6. Idea Association.-Is faulty as a rule. The goal idea is not 
reached. 
7. Memory.-At the onset of the disease memory is not much 
impaired, though states of amnesia may exist. 
8. Emotions.-There is usually a marked state of indifference, 
a condition of emotional poverty; the emotions are very unstable; 
a condition of emotional ataxia exists. 
9. Judgment.-Judgment is materially impaired. 
10. Nervous System.-Tendon reflexes are frequently disor- 
dered, usually increased; the pupils are often dilated and unequal 
at times; a sluggish reaction to light is often observed. Epilep- 
tiform attacks are common. Hysterical convulsions occasionally 
occur. Vasomotor disturbances are frequent. Blueness of the 
hands and feet is common, as is the general condition of derma- 
tographia. 
11. Behavior.-Behavior is silly, childish, and often impulsive. 
Very often there is a repetition of senseless acts and senseless 
words and phrases. Negativism and mutism are common. 250 
MANUAL OF PSYCHIATRY 
12. Sleep.-Sleep is often disturbed and attended by wild and 
fearful dreams. 
In the various forms of dementia praecox, which were de- 
scribed in the previous chapters, it was found that certain 
types of symptoms already mentionel showed special develop- 
ment. 
PARANOIA 
Paranoia is a disease which usually develops in adult life, 
and the outstanding qualities upon which it is erected are such 
states of mind as conceit and suspicion. 
1. Onset.-Onset is slow, insidious. 
2. Consciousness is clear. 
3. Orientation.-Orientation is usually correct, except in the 
period of explanation when the personality is changed. 
4. Hallucinations.-Very rare; usually absent. 
5. Delusions.-Delusions are always present; are more or less 
systematized. The delusions are of reference, persecution, or of 
expansive nature. Sometimes the delusional systems present 
considerable truth, but the facts are falsely interpreted. 
6. Idea Association.-Is rapid. The goal idea is reached. 
7. Memory.-The memory is not impaired, except in the period 
of the disease when the personality is changed and then there 
are retrospective falsifications of memory. 
8. Emotions.-The emotions are fairly stable, except as asso- 
ciated with the delusional beliefs, when there may be violent 
outbreaks of temper, and the performance of criminal acts. 
9. Judgment.-The judgment is impaired by reason of the 
delusional conceptions which the patient entertains. 
10. Nervous System.-The symptoms are negative. 
11. Behavior.-The behavior is fairly normal, except when 
regulated by delusional beliefs. (See above.) 
From the ranks of the paranoiac come many religious reform- 
ers and zealots, would-be political leaders, curbstone orators, DIAGNOSTIC GROUPINGS OF SYMPTOMS OF PSYCHOSES 
251 
assassins of public men, dilettante amorous poets, and radical 
leaders of labor organizations. 
MANIC-DEPRESSIVE PSYCHOSES 
The manic-depressive psychoses usually occur during the 
second, third and fourth decades of life, and are characterized 
by periods of excitement and depression of varying degrees and 
intensity. The patients recover from these attacks without 
mental deterioration. These attacks last from a few days or 
weeks to months and years. The interval between attacks may 
be of a few days, months or years. 
1. Onset.-It may be sudden or gradual. 
2. Consciousness.-Consciousness is usually clear, except in 
the profound depressions of the depressive type, and in the 
profound excitements of the manic type. 
3. Orientation.-Orientation is not usually much disturbed, 
except in the delirious and delusional forms of both phases of 
this disorder. 
4. Hallucinations.-In the severer forms, hallucinations may 
be present. 
5. Delusions.-Delusions frequently occur in both the manic 
and depressive forms of this disorder. 
6. Idea Association.-In the manic phase of this disorder, 
there is found the condition of "flight of ideas." In the depressive 
phase, there is a very marked psychic retardation and often a 
fixity of ideas. 
7. Memory.-Memory is not, as a rule, much impaired. The 
patient very frequently shows amnesia for the attack. 
8. Emotions.-Depression and sadness in depressive phase. 
Exaltation, irritability and rapid change in manic phase. 
9. Judgment.-Judgment is materially impaired during the 
attacks of both phases. 
10. Nervous System.-Negative. 252 
MANUAL OF PSYCHIATRY 
11. Behavior.-In the manic phase, the patient may be elated, 
restless, and show great psychomotor activity, all of which results 
in rather silly, extravagant conduct. In the depressive phase, 
there is great psychomotor retardation resulting in a very marked 
reduction of physical activity. The patient sits around very 
often in an attitude of despondency and despair. Suicide is 
often the termination of the depressive phase. 
Occasionally we encounter, during the depressive phase, states 
of profound melancholia, attended by delusions and hallucina- 
tions of a most absurd character. Frequently we see melan- 
cholic states which are attended by delusions of persecution and 
reference. States of delirium in which consciousness is profoundly 
clouded are observed. Hallucinations and delusions usually 
accompany this form. Mixed types of the manic depressive 
psychoses frequently occur. 
INVOLUTIONAL MELANCHOLIA 
Involutional melancholia belongs to the manic-depressive 
group of psychoses, but its symptoms are so characteristic that 
it has acquired a definite identity. This psychosis occurs in 
women during the involutional period from 40 to 60 years, and 
in men from 45 to 60 years. There are usually marked evidences 
of the period of involution. 
1. Onset.-The onset usually is slow and insidious. 
2. Consciousness.-Is usually clear, but the patient is occa- 
sionally confused during periods of agitation, delirium, or stupor. 
3. Orientation.-Orientation is not disturbed, as a rule, except 
Vrhen the depressive states are so profound as to interfere with 
the perception of the environment. 
4. Hallucinations.-These are not very common, and when 
they exist are usually of a very disagreeable nature. 
5. Delusions.-Delusions of a depressive nature are the out- 
standing characteristics of this disorder. They are concerned 
with ideas of sin, poverty, catastrophes of all sorts, and disease' DIAGNOSTIC GROUPINGS OF SYMPTOMS OF PSYCHOSES 
253 
6. Idea Association.-This is retarded and limited. The patient 
is only concerned with his delusions. 
7. Memory.-Memory for remote events is good; poor for 
recent events because the patient pays little attention to the 
happenings in his environment. 
8. Emotions.-The patients are obsessed with fears which 
relate to their depressive delusions. They are very apprehensive, 
always anxious and worried. 
9. Judgment.-Judgment is impaired. 
10. Behavior.-The patients are introspective, self-analytical, 
take no interest in their environment, often remain in fixed 
positions for hours, moaning and groaning; frequently they are 
very much agitated, and go about wringing their hands. They 
often commit suicide. 
11. Sleep.-They suffer from insomnia; sleep is disturbed by 
fearful dreams. 
GENERAL PARESIS 
This disorder usually makes its appearance during middle age, 
and is characterized by progressive mental enfeeblement, which 
terminates in a state of absolute dementia. It is attended by 
marked changes in the central nervous system, manifested by 
disorders of the cranial nerves, of the reflexes, and defects of 
muscular co-ordination which eventually lead to a condition of 
general paralysis. The Wasserman reactions of the blood cere- 
brospinal fluid are positive in practically all instances. The cell 
count in the cerebrospinal fluid is increased. 
1. Onset.-The onset is usually slow and is marked by a 
neurasthenic group of symptoms. 
2. Consciousness.-Consciousness is early impaired. The pa- 
tient acts as if he were in a dream-like state, somewhat resem- 
bling the condition of mild intoxication. In the latter stages 
consciousness is profoundly clouded. 254 
MANUAL OF PSYCHIATRY 
3. Orientation.-At first not much disorder; later, very greatly 
disordered, especially with reference to time. 
4. Hallucinations.-They are very common, usually quite 
absurd. 
5. Delusions.-Usually present. They are absurd and bizarre, 
often of the expansive character, i. e., delusions of wealth, of 
strength of body and mind, of great political power, etc. 
6. Idea Association.-Very defective. 
7. Memory.-Becomes defective very early in the course of 
the disease. 
8. Emotions.-The patient is usually euphoric; has states of 
exaltation. Occasionally, in the early stages of the disease, the 
patient may be very much depressed, although the period of 
depression is usually short. Occasionally there are violent out- 
breaks of temper and passion. 
9. Judgment.-Very much disordered in the early stages; dis- 
appears altogether in the latter stages. 
10. Behavior.-The behavior is childish and foolish; moral 
dilapidation is usually present; offenses are committed against 
social conventions; crimes are frequent. The patients often 
make foolish speculations, sometimes dissipating the accumula- 
tions of a lifetime in absurd investments and senseless gifts. 
11. Sleep.-Sleep is disturbed in various ways. Often we find 
the patient very somnolent and stuporous during the day. This 
condition may continue through the night. In other cases, the 
patient may suffer from the most aggravated form of insomnia, 
or the sleep may be disturbed by intense headaches and terrifying 
dreams. 
SENILE PSYCHOSES 
Senile dementia is a chronic, progressive psychosis occurring 
during the senile period of life. It is attended by chronic and 
progressive failure of the mental powers and terminates in death. 
1. Onset.-The onset is usually slow. DIAGNOSTIC GROUPINGS OF SYMPTOMS OF PSYCHOSES 
255 
2. Consciousness.-Is clouded and befogged, especially in the 
severer types. 
3. Orientation.-In all forms, orientation is disturbed in one 
or more spheres, and in the severer types, disorientation is com- 
plete in all spheres. 
4. Hallucinations.-These are common. 
5. Delusions.-Are very frequent. They are chiefly concerned 
with ideas of suspicion, persecution, poverty, and occasionally 
they are the expansive type. 
6. Idea Association.-Is very limited and often nil. 
7. Memory.-Memory for remote events may be retained for 
quite a while; memory for recent events very slight, if present 
at all. 
8. Emotions.-The emotions are very unstable. Irritability, 
excessive anger, excessive greed, and egotism are often found. 
The patient is often extremely indifferent and lacking in the 
usual sympathies. 
9. Judgment.-Judgment is markedly impaired. 
10. Behavior.-Some patients are quiet, well-behaved; others 
are quarrelsome and combative, occasionally given to sexual 
deviations, commiting rape, incest, and acts of exhibition. Not 
infrequently they commit other serious crimes. 
11. Sleep.-Senile dements as a rule suffer from insomnia. 
ARTERIOSCLEROTIC PSYCHOSES 
Arteriorclerotic psychoses belong to the senile group of insani- 
ties and make their appearance, as a rule, just previous to the 
senile period. In addition to age, heredity predisposition, over- 
work, alcohol and syphilis contribute largely to the production 
of this disorder. 
1. Onset.-The onset is usually slow. 
2. Consciousness.-Usually impaired, especially in the severer 
forms. 256 
MANUAL OF PSYCHIATRY 
3. Orientation.-Orientation is disturbed in varying degrees 
in one or all spheres. 
4. Hallucinations.-Are quite common. 
5. Delusions.-Delusions are found in practically all cases. 
Often they are of the paranoid type and frequently have a sexual 
coloring. Delusions of infidelity are very common. 
6. Idea Association.-Idea association is markedly impaired. 
7. Memory.-Memory is impaired for recent events. Memory 
for remote events is retained for some length of time. 
8. Emotions.-These are unstable. The patient cries and 
laughs without provocation; is subject to attacks of marked 
depression; is often lacking in normal sympathies. 
9. Judgment.-As a rule judgment is not as much impaired in 
this psychosis as in senile dementia. The patient often has some 
insight into his condition. 
10. Nervous System.-Marked changes in the pupils are noted; 
the tendon reflexes are disordered; sensory and motor aphasia, 
paraphasia and agraphia are found. Convulsions are quite 
frequent; these are due to apoplectic attacks. 
11. Behavior.-These patients sometimes commit crimes, dis- 
regard social conventions, are often restless and excited. Some 
patients suffer from aboulia. 
12. Sleep.-These patients suffer from insomnia at night-time 
and during the day-time they are quite drowsy and sleepy. 
NEURASTHENIA 
1. Onset.-The onset is usually slow. 
2. Consciousness.-Is clear. 
3. Orientation.-There is no disturbance. 
4. Hallucinations.-There are none. 
5. Delusions.-None. 
6. Idea Association.-No defect. 
7. Memory.-There is no impairment. DIAGNOSTIC GROUPINGS OF SYMPTOMS OF PSYCHOSES 
257 
8. Emotions.-The emotions are easily disturbed. The patient 
is irritated by trifles, is easily depressed, is quite pessimistic; 
is given to self-analysis and introspection. 
9. Judgment.-No impairment of the processes of judgment. 
10. Nervous System.-The tendon reflexes are usually in- 
creased; the patient is extremely susceptible to the effect of 
sudden noises, and often very sensitive to light. This condition 
of hyperesthesia is very common. A'condition of paresthesia is 
often noted. Headaches and vague pains about the body are 
complained of. The patient has an exaggerated sense of fatigue. 
11. Behavior.-The patient finds it very difficult to apply 
himself to daily occupations because of the pains which he suffers 
and the sense of fatigue which he experiences. Occasionally he 
neglects his work, takes rest cures to rid himself of his disorder. 
He is extremely susceptible to the machinations of the quack, 
takes all sorts of nostrums, becomes a disciple of the various 
"new-thought" systems. He rehearses to his friends and rela- 
tives his symptoms; becomes quite irritable and grouchy if they 
are not ready listeners. 
12. Sleep.-Is usually disturbed; is fitful; unpleasant dreams 
are common. Sometimes aggravated forms of insomnia are 
observed. 
HYSTERIA 
Hysteria is a disorder occurring usually during adolescence, 
or in early adult life, though it may occur at any period, and is 
based upon an innate predisposition; it is excited by severe 
emotional shocks and traumatisms. 
1. Onset.-The onset is usually slow; occasionally it appears 
to be very rapid, following some emotional shock. 
2. Consciousness.-Is usually clear. Occasionally there are 
types in which consciousness is confused, clouded, or stuporous. 
3. Orientation.-Orientation is not disturbed as a rule, except 258 
MANUAL OF PSYCHIATRY 
in some of the stuporous or befogged states which are occasion- 
ally noted. 
4. Hallucinations.-These rarely occur. 
5. Delusions.-These rarely occur. 
6. Idea Association.-It is somewhat limited on account of 
the patient's mental disassociation. 
7. Memory.-Occasionally there are states of amnesia which 
may be total or partial. 
8. Emotions.-The emotions are unstable; the patient is given 
to rapid changes; cries and laughs without adequate reason; is 
extremely selfish and often morally obtuse. 
9. Judgment.-Judgment is usually impaired. 
10. Nervous System.-Sensory disorders are noted. Condi- 
tions of anesthesia and hyperesthesia are found. The "glove and 
stocking" sensations are noted. The visual fields are frequently 
contracted. Blindness, hemianopsia, achromatopsia, micropsia, 
diplopia and scotomata, etc., are found. The patient is usually 
unaware of the conditions of anesthesia which exist; the anes- 
thetic zones are changeable, and they do not follow the anatomi- 
cal distribution of the nerves. Convulsive attacks are noted, 
which may be of minor or major form. There may be paralyses 
of any of the extremities. Rhythmical spasms are common 
which manifest themselves in conditions of torticollis, coughing, 
winking, hiccoughing, grunting, sobbing, choreiform movements, 
various types of tremors, etc. The reflexes are preserved, though 
they may occasionally be exaggerated. 
11. Behavior.-The behavior is many times silly, foolish, 
erratic. Conduct is governed by whims. They make serious 
efforts to evoke the sympathies of those about them; make 
apparent attempts at suicide in melodramatic ways. Their acts 
indicate disorders of the sexual instinct which manifest them- 
selves by erotic behavior, forms of sexual perversity; sexual 
frigidity is common. Occasionally the patients appear to have DIAGNOSTIC GROUPINGS OF SYMPTOMS OF PSYCHOSES 
259 
dual personalities, and the conduct of these apparent personali- 
ties is diametrically opposed, one to the other. 
12. Sleep.-They often suffer from insomnia; sleep is dis- 
turbed by terrifying dreams, dreams of a sexual nature, and 
dreams of wish-fulfilment. States of somnambulism are frequent. 
(See Table of Differentiation between Hysterical and Convulsive 
Attacks in Chapter No. XVIII.) CHAPTER XXII 
METHODS OF EXAMINATION 
In order to make a correct diagnosis and treat and care for 
a psychiatric patient successfully it is necessary for the exam- 
iner to have an accurate and comprehensive conception of the 
patient. That the examiner may secure an accurate idea of 
the patient it is necessary to examine him in the utmost detail 
and in the most searching manner, outlined under the following 
captions: 
a. .Family history. 
b. Personal history. 
c. History of the present illness. 
d. Physical examination of the patient. 
e. Neurological examination of the patient. 
/. Mental examination of the patient. 
Family History.-The family history is an extremely impor- 
tant item. An effort must be made to discover the existence of 
mental, neurological and constitutional diseases in the ante- 
cedents of the patient. This information is to be obtained from 
relatives, friends, and possibly from state officials who may 
have had the patient in charge at one time, and from the patient 
himself. It must be borne in mind that because of family pride 
the relatives may attempt to deceive or mislead, and the patient 
because of his mental state may be unable to give accurate 
information. The important items to be covered in the history 
taking are the absence or presence of insanity, nervous disease, 
alcoholism, drug addiction, crime, suicide, tuberculosis, syphilis, 
arthritis or other constitutional disease in the parents, grand- 
260 METHODS OF EXAMINATION 
261 
parents or collateral relatives. In securing this information the 
examiner will obtain indirectly a great amount of information 
concerning the environment under which the individual was 
born and in which he has lived. 
Personal History.-The personal history should begin with 
the prenatal conditions. It should be ascertained whether the 
parents suffered from any constitutional disease at the time of 
conception or during the period of gestation, whether the patient 
was born in a natural manner or whether forceps were used in 
delivery, whether the labor was long and tedious, or whether 
any form of obstetrical difficulty existed. 
The individual's life should be carefully traced through his 
childhood to ascertain at what age he learned to walk and talk, 
the age at which he commenced school, when schooling was 
stopped, and the progress the patient made at school. A careful 
record should be made of injuries of all sorts, of the patient's 
use of alcohol or other narcotic drugs, whether or not he acquired 
venereal diseases, and, if these were acquired, how carefully and 
persistently they were treated. 
The sexual habits of the patient should be determined. It 
should be learned at what age the sexual impulse first appeared, 
and what emotional manifestations accompanied it. All experi- 
ences at the age of puberty, whether sexual, religious or of other 
emotional nature, should be accurately recorded; also whether 
or not the patient indulged in masturbation (occasional or exces- 
sive), or in illicit sexual intercourse, and the emotional experi- 
ences which attended such practices should be noted. If married, 
it will be necessary to discover whether or not the married life 
has been happy or unhappy, and if unhappy, the cause, if pos- 
sible. Great care should be exercised in securing information 
about the married life, as the patient may be very sensitive and 
easily offended. If the patient is a woman it is particularly 
necessary to learn when menstruation began; whether she is 262 
MANUAL OF PSYCHIATRY 
married, and if so, at what age the marriage was contracted; 
whether she has borne a child or suffered from abortions or 
miscarriages; whether her pregnancies have been numerous and 
at short intervals, and whether labor has been attended by mental 
and nervous manifestations. All diseases of adult life should be 
carefully recorded. 
In securing all this information the examiner learns a great 
deal of the mental make-up of the patient, the character of his 
personality, the environmental conditions under which he has 
lived, whether or not the patient has made a successful social 
adjustment, and whether he has had the capacity to adapt him- 
self to his environment in a satisfactory way. In the securing 
of the family and personal history the patient will many times 
betray his delusions and hallucinations and furnish a fund of 
information which may be the key to the mental diagnosis. The 
patient will show whether he is elated, depressed, or nonchalant. 
History of the Present Illness.-The manner of onset of the 
patient's disease is very important. Did he suffer from a physi- 
cal or mental shock previous to the development of his mental 
or nervous disorder? Was he undergoing any sort of strain or 
suffering from any stress? Did a change occur in his physical 
condition or in his mental make-up? Did he behave in an 
unusual and extraordinary manner? Usually in the insane there 
is a change in the patient's habits. He may suffer from insomnia, 
become irritable and morose, eat but little, lose weight, complain 
that he hears imaginary voices. His hair may become gray or 
whitened. He may admit that he has thought of suicide or has 
even attempted self-destruction. Careful inquiries should be 
made of the patient and his family and relatives to ascertain 
whether he has displayed any homicidal tendencies. The patient 
may or may not have insight into his condition. He may or 
may not know that his memory is failing; that he has difficulty 
in remembering to carry out the details of his business affairs. METHODS OF EXAMINATION 
263 
He may realize that he finds it difficult to make adjustments to 
new situations in which he finds himself. Often the patient 
understands that he is failing mentally and is very much dis- 
tressed about his condition and seeks the advice of the physician. 
Another patient may be wholly unaware that any change has 
taken place in his mental status. Any information that may 
shed light upon the patient's condition is to be recorded. No 
details are too trivial to be noted, as they may have some bearing 
upon the patient's psychosis. 
Physical Examination of the Patient.-A careful inspection 
of the patient is always in order. During the physical examina- 
tion it may be determined whether or not he is sad, cheerful or 
excessively happy, whether he is suspicious, irritable, hostile, 
belligerent or dangerous. His movements are to be observed; 
whether they are accurate, quick and purposeful, or whether 
they are slow, indicative of depression, or without purpose, as 
in states of confusion and delirium. The patient's general ap- 
pearance often gives very valuable information as to his mental 
condition. It should be noted whether his clothes are properly 
buttoned, whether they are clean or stained with food or soiled 
with body secretions, whether he is slouchy and unkempt, or 
whether he is exceedingly fastidious or gaudily dressed, or deco- 
rated with trinkets or badges. Observation should be made as 
to whether the patient is communicative or reserved, whether 
or not he makes spontaneous complaint of his condition or 
whether he must be urged to tell of his disorder, whether he is 
negativistic or absolutely mute. The depression of the melan- 
choly patient is evidenced by his attitude and behavior. The 
paretic may be gaudily dressed, extremely euphoric and happy 
out of all proportion to his physical state and his environment. 
Following the inspection a careful physical examination of 
the patient should be made. His general stature should be noted; 
whether or not there is malformation of the skull, asymmetry 264 
MANUAL OF PSYCHIATRY 
of the face or body. The skin should be carefully examined for 
scars and eruptions. The mucous membrane of the mouth should 
be inspected for the presence of mucous patches and scars on 
the sides of the cheek or tongue. It should be noted whether 
it is anemic or pale, or whether there are signs of cachexia due 
to cancer, pernicious anemia or other malignant disease. The 
osseous system should be examined, as should the respiratory, 
circulatory, digestive, glandular and genito-urinary systems. 
Urinalysis should always be made. The Wassermann test should 
be made of the blood and spinal fluid if indicated. Great care 
should be taken to discover the presence of all serious disease 
such as nephritis, diabetes, exophthalmic goiter, tuberculosis, 
syphilis, gonorrhea, metallic poisonings, gastro-intestinal disor- 
ders or intestinal parasites. In a word, the physical examination 
must be made in a painstaking, careful, searching manner. All 
possible physical disease should be eliminated. 
Neurological Examination of the Patient.-The eyes should 
be examined to determine whether the pupils react to the usual 
tests, whether the movements of the eyeballs are normal, whether 
there is any constriction of the visual fields or disease of the 
retina or optic tract. The other cranial nerves should receive 
the necessary attention and any defect that may exist should 
be properly noted. The tendon reflexes should next be examined. 
The elbow and wrist jerks, the patellar tendons and the tendo- 
Achilles should all be carefully examined. The superficial 
reflexes, including the corneal, pharyngeal, abdominal and cre- 
masteric and plantar, should be examined. The customary 
coordination tests such as the finger-finger test, the finger-nose 
test and the knee-heel test, should be employed to discover the 
absence or presence of difficulties of coordination. The gait is 
to be examined by having the patient walk with his eyes open 
and closed. The muscle sense is to be tested by having the 
patient obey simple commands involving muscular movement. METHODS OF EXAMINATION 
265 
General sensation should be tested on the various portions of 
the body by the use of a camel's-hair brush or wisps of cotton, 
and by touching the patient with the point and head of a pin. 
Conditions of hyperesthesia, paresthesia and analgesia are to 
be looked for. The thermal sense may be tested by touching the 
patient with steel rods which have been chilled or heated in cold 
or hot water. 
Careful investigation should be made of the patient's subjec- 
tive sensations. The examiner should learn whether the patient 
has pain in any portion of his body, tenderness of nerves, tin- 
glings, numbnesses, formications, or peculiar sensations of any 
sort. The presence or absence of tics should be noted. The 
history of attacks of syncope, spasms or convulsions should be 
carefully noted. Occasionally the examiner has the opportunity 
to see the patient in a convulsion. In such an event the character 
of the convulsive attack should be very carefully recorded. In 
those cases where it is indicated a cytological examination should 
be performed so that organic and functional diseases of the brain 
and spinal cord may be properly differentiated. This examina- 
tion includes the general appearance, pressure determination, test 
for sugar and specific gravity, bacterial count, cell count, albumin 
determination, the various globulin tests and the Wassermann 
reaction. 
A synoptical outline of the most important details is given 
below for the examiner to follow and elaborate to suit the needs 
of the case in hand. No attempt has been made to describe 
the various methods of neurological technique, as it is taken for 
granted that the reader is familiar with them. 
Cranial Nerves.-I. Olfactory.-Smell should be tested by 
using fragrant essential oils. Each naris should be tested sepa- 
rately. The patient should be interrogated as to odors of a 
subjective nature which relate to himself or his environment. 
II. Optic.-The visual fields should be tested with special 266 
MANUAL OF PSYCHIATRY 
relation to contractions, hemianopsia, color vision, visual ca- 
pacity, fundi examination and visual hallucinations. 
Ill, IV and VI. Oculo-motor, Patheticus, Abducens.-The 
movements of the eyeball in all directions-up, down, lateral 
and rotary. Nystagmus, whether lateral, vertical or rotary. 
The presence of squints, ptosis or diplopia. Pupils-outline 
size, whether equal or not. Reaction to light. Reaction to 
accommodation. Consensual reflex. Sympathetic reflex. 
V. Trigeminus.-Determine condition of the conjunctival, 
corneal and palpebral reflexes. Movements of mastication. 
Taste to be tested by the use of sour, salt, sweet and bitter sub- 
stances. Salt, quinine, sugar and dilute acetic acid may be used 
for these tests. The mouth should be cleansed after each test. 
Determine whether or not the patient has a subjective taste 
which may refer to poison. 
VII. Facial.-Note condition of facial muscles; whether there 
is drooping of one side of the face; 'whether the teeth show 
on one side of the face; the presence or absence of wrinkles, 
whether bilateral or unilateral; the ability of the patient to 
whistle; whether the facial muscles jerk when the patient talks; 
puffing of the cheeks; tremor of the muscles of the face on 
retracting the lips from the teeth; atrophy of the muscles of 
the face; paralysis of the facial muscles. 
VIII. Auditory.-Acuity of hearing, defects of hearing, deaf- 
ness in any degree. Employment of the various tests of hearing 
for air and bone conduction. Whispered voice, watch, and tuning 
fork tests. Stethoscope test: Place the earpieces of the stetho- 
scope to patient's ears; place a watch on the drum or at the 
bowl of the stethoscope. Pinch the tubes of the stethoscope so 
as to close one of the tubes when testing the different sides. 
This test is fairly reliable. Auditory hallucinations. Ringing 
in the ears. Dizziness (vertigo), objective type, when the patient 
actually staggers or reels, subjective type, when the patient METHODS OF EXAMINATION 
267 
feels as though he is going to stagger or fall, but no movement 
occurs. Caloric reactions to be tested if indicated. 
IX. Glossopharyngeal.-Apply the tests for taste, to the poste- 
rior third of tongue. 
X. Vagus.-Inspect the palate at rest and in phonation-have 
the patient say "ah." Note sensibility of palate; the integrity 
of the act of swallowing. 
XI. Spinal Accessory.-Have the patient rotate his head, look 
downwards and upwards, raise the shoulders. 
XII. Hypoglossal.-Note accuracy of the movements of the 
tongue; whether the tongue is protruded to the right or left or 
in the median line, whether tremors are present or not and of 
what type; whether there is atrophy or hypertrophy of the 
tongue. 
Superficial Reflexes.-Test the corneal, pharyngeal, abdominal, 
cremasteric and plantar reflexes, noting any changes from the 
normal. 
Deep Reflexes.-These are to be tested in order; the corruga- 
tor supercilii, jaw, triceps, biceps, periosteoradial, patellar and 
Tendo-Achilles reflexes. 
Organic Reflexes.-The rectal and bladder reflexes. 
Coordination Tests.-Finger-finger test; finger-nose test, knee- 
heel test; walking backwards and forwards with eyes open and 
shut; pointing tests. Determine accuracy, rapidity, force of 
movements, peculiarities of gait such as the spastic, steppage, 
ataxic, cerebellar, hemiplegic and propulsive gaits. Test for 
Romberg sign. Make general examination of motor system. 
Motor Speech.-Have patient repeat the following words and 
phrases: Methodist Episcopal, statistical, perturbation, Con- 
stantinople, black bug's blood, red riding artillery brigade, 
Commonwealth of Massachusetts. 
Handwriting.-Note character, tremors, ataxia, whether letters 
or syllables are left out. 268 
MANUAL OF PSYCHIATRY 
Sensory Functions.-Pain sense, temperature sense, muscle 
sense, sense of position, epicritic and protopathic sensibilities, 
stereognostic sense, presence or absence of apraxia, sensitiveness 
of nerve trunks, hysterogenic zones. 
Subjective Sensations.-Formications, tinglings, numbnesses, 
anesthesia, paresthesia, acroparesthesia, analgesia, pain. 
Organic Sensations.-Thirst, hunger, fatigue, sexual desire, 
desire for urination and defecation. 
Tremors.-Character of tremors, if present. 
Convulsions and Tics.-Absence or presence of tics. History 
of spasms or convulsions. Vasomotor and secretory disturbances, 
trophic disturbances. 
Electrical Reactions.-Mysathenic Reaction, Myotonic Reac- 
tion, Tetanic Reaction, Reaction of Degeneration. 
Sleep.-Character of sleep, disturbances. 
MENTAL EXAMINATION 
The purpose of the mental examination is to discover whether 
or not there are disturbances of consciousness, the presence or 
absence of hallucinations or delusions, disorders of orientation, 
disturbances of perception or apprehension, defects of attention, 
disorders of memory, disturbances of train of thought, defects 
of reason and judgment, and abnormalities of the emotions and 
impairment of will-power which lead to disorders of conduct. 
The examination should be thorough, searching and in detail, 
and if it is possible, especially in medico-legal cases, the answers 
to all questions asked by the examiner should be recorded. The 
patient is to be examined, so far as possible, by standards which 
relate to himself and not by those of the examiner. The patient's 
physical condition, his social relations and the environment under 
which he has lived, should be carefully considered. Due allow- 
ance must be made for his educational advantages or lack of 
educational advantages, and his general experiences must be METHODS OF EXAMINATION 
269 
carefully weighed before conclusions are drawn concerning his 
mental status. The following scheme of examination will be 
of service as an outline. It may be varied to suit the indi- 
vidual case, but the essential items mentioned should have close 
attention. 
Attitude and Manner.-The examiner should note the gen- 
eral appearance of the patient, the condition of his clothing, 
whether he is dirty or is grotesquely dressed, whether or not 
he is quiet and calm, excitable or belligerent, depressed or unduly 
elated. Peculiar gestures or mannerisms should be noted. The 
patient may be mute or he may be extremely talkative; may be 
quiet or constantly in motion. 
Mental Makeup.-It is apparent to the careful examiner that 
the insane show various types of temperamental constitution, as 
do the sane, and these temperamental characteristics may be 
fairly well classified and have some psychiatric value. In record- 
ing the examination it should be noted whether or not the 
patient's mental make-up may be classified under one or more 
of the following types: 
(a) Seclusive Type.-Within this category are to be included 
persons who are exceedingly retiring, bashful, introspective, 
fearful, shy and secretive. 
(b) Manic Type.-This term is used to indicate persons who 
display excessive mental and physical activity, are garrulous, 
boastful, exalted, abnormally optimistic, self-opinionated and 
blustering. 
(c) Depressive Type.-Persons with this mental makeup are 
just the opposite of those of the manic type. They are given to 
excessive worry, are easily moved to tears, are easily discour- 
aged, slow in physical and mental movement, and act as though 
inhibited and restrained. They are noncommunicative and 
unduly depressed. 270 
MANUAL OF PSYCHIATRY 
(d) Paranoid Type.-Persons of this constitutional makeup 
are exceedingly suspicious; do not trust those about them; put 
paranoid interpretations upon the conduct of others. Their 
feelings are easily hurt. They complain of discrimination on 
the part of others; see sinister motives in the conduct and 
behavior of others; are always justifying their own conduct and 
behavior. Sooner or later they become exceedingly egotistical; 
act in a superior manner. Their conversation is chiefly con- 
cerned with themselves. They are given to the excessive use of 
the pronoun I. 
(e) Irritable or Faultfinding Type.-Individuals who fall 
within this group are given to excessive faultfinding, to out- 
breaks of temper over the most trifling circumstances, and to 
cruel and impulsive acts. 
(f) Unstable or Hysterical Type.-Individuals whose person- 
ality falls within this category have mercurial temperaments. 
They may laugh or cry within the space of a few seconds. They 
respond to slight suggestions and are subject to whims. They 
cannot be relied upon; will be friendly one day and, without 
cause, unfriendly tomorrow; one day enthusiastic, another day 
depressed and uninterested. The emotions are subject to con- 
stant change. 
(g) Erotic Type.-Persons within this group give evidence of 
an intense sexual nature. By their conduct and conversation 
their sex content of consciousness is displayed. Occasionally 
they may display evidences of sexual perversions and inversions, 
which are described in the chapter on Constitutional Psycho- 
pathic Inferiority. 
(A) Criminalistic Type.-Persons who belong to this group 
boast of anti-social traits and of criminal acts which they may 
have committed. They ridicule the law restraining conduct. 
They are indifferent to the legal rights of others. They stoop 
to various criminal acts to obtain their own ends. Within this METHODS OF EXAMINATION 
271 
group are to be found the near reformers, curbstone socialists, 
I. W. W.'s and labor agitators. 
Spontaneous Complaint.-Many patients will without urg- 
ing make complaint of their mental or physical condition. In 
so doing they may give expression to delusions or hallucinations. 
They may more or less describe the onset, development and 
course of the psychosis. The spontaneous complaint should be 
carefully recorded as a stenogram, for it may contain the key 
to the analysis of the patient's mental status. 
Emotional Status.-The emotional status should be carefully 
recorded as the patient's emotions are subject to change and 
may be at opposite extremes at various times. It should be 
noted whether the patient is unduly elated, euphoric or happy 
out of all proportion to his physical condition and his environ- 
ment. The patient may be indifferent. This indifference may 
be of a mild or very pronounced degree. He may be so indiffer- 
ent as to appear to have some clouding of consciousness. He 
may take no notice of any circumstances within his environment. 
Again, a condition of negativism is found. The patient refuses 
to talk, resists every effort that is made for his comfort. When 
he is told to open his eyes he closes them. If asked to show his 
tongue he will not do so. He does the reverse of practically 
everything that is asked of him. According to the psychosis 
from which the patient suffers, he may be mildly or excessively 
depressed, he may be lachrymose, sit in an attitude of absolute 
despair, apparently oblivious to all his surroundings. Some 
patients are excitable, irritable, threatening, and at times given to 
assault. 
Stream of Mental Activity.-It should be carefuly noted 
whether or not the patient's conversation is relevant and co- 
herent, whether or not he reaches the goal idea in his conversa- 
tion, whether he is spontaneous or reticent. Flight of ideas may 
be observed. The patient's conversation may be a "word salad" 272 
MANUAL OF PSYCHIATRY 
-an incoherent jargon. A maniacal patient may be facetious 
in his remarks, but owing to the pressure of ideas his words and 
statements are entirely disconnected. In dementia there may be 
a condition of echolalia. The patient may constantly repeat 
some senseless words or phrases. The conversation often sheds 
light on the diagnosis. The patient may exhibit in his conver- 
sation his delusions in a systematized or confused manner, 
according to the character of his psychosis. A stenogram of the 
patient's conversation should be taken whenever possible. This 
is especially valuable in medico-legal cases. 
Hallucinations.-Hallucinations are of an auditory, visual, 
olfactory, gustatory, tactile or somatic nature, according to their 
content. The patient should be very carefully questioned in a 
tactful manner, so that he may give expression to the false 
beliefs he may entertain. He may explain that he hears people 
talking to him, making disrespectful and uncomplimentary 
remarks. He may converse with the Lord. He may interpret 
the blowing of the wind through the trees as communications 
from spirits to him. These things may be told spontaneously 
or the patient may have to be gently urged to give expression to 
his hallucinations. Often the patient may feel that he smells 
disagreeable and vile odors; that they are injected into his room 
at night over the transom or at the bottom of the door. Again, 
he may smell the most fragrant perfumes at night, sent to him 
by secret lovers or by sympathetic friends. When olfactory 
hallucinations exist, gustatory hallucinations are usually pres- 
ent. The patient tastes a metallic substance in his food; com- 
plains that he is being poisoned; that vile substances are being 
put into his milk and into his water. 
Visual Hallucinations.-Such hallucinations occur in alcohol- 
ism, when the patient sees rodents, snakes, and all manner of 
living objects. Other patients may say that they see God; that METHODS OF EXAMINATION 
273 
they have visions such as Jacob had when the angels descended 
from heaven by a ladder. 
Tactile Hallucinations.-Patients may feel that bugs are 
crawling under the skin; that snakes are crawling over them; 
that the fingers feel like inanimate substances. 
Somatic Hallucinations.-The patient entertaining hallucina- 
tions of this sort may feel as though his limbs are missing; that 
his blood is dried up; that he has no head; that he cannot see; 
that he has some live object in his intestines or stomach; that 
several persons are in his head and holding a conversation. He 
often feels as though a voice comes from his stomach. 
Delusions.-Delusions are to be elicited in the same manner 
as are hallucinations. Unless the patient spontaneously de- 
scribes them, they should be tactfully elicited by indirect and 
direct methods. The delusions may be systematized, unsystema- 
tized, transient, fixed or changeable. Often they are supported 
by more or less logical argument, as is the case in paranoia. 
A delusional interpretation may be put upon actual facts and 
great care must be exercised to distinguish facts from delusions, 
especially in alcoholic hallucinosis. The patient should be care- 
fully interrogated about his delusional beliefs, and the types that 
are expressed may be pathognomonic of the disease from which 
the patient suffers. He may be asked questions to determine 
whether or not he entertains ideas of unworthiness, whether he 
believes he has committed the unpardonable sin and is doomed 
to eternal punishment, whether he fears he will die in the poor- 
house, whether he believes he will be committed to prison, 
whether or not he believes he is suffering from some constitu- 
tional disease, as syphilis, cancer, tuberculosis or Bright's disease. 
He may tell, without questioning, of the existence of nihilistic 
ideas, complaining that he is dead, that his limbs are missing, 
that he is petrified. He may volunteer the statement that he is 
spied upon by his enemies, that they poison his food, that he is 274 
MANUAL OF PSYCHIATRY 
insulted, that he is robbed of his money and cheated of his 
political rights. Grandiose ideas are common. The patient may 
believe that he is a millionaire, that he is the ruler of the 
universe, that he is God, that he possesses the most powerful 
mentality in the world, that he is the strongest man in the 
world, etc. Any sort of combination of hallucinations and 
delusions may be expected. 
Insight.-This is determined by asking the patient such ques- 
tions as "Where are you?" "Are you sick?" "How do you feel?" 
"Is there anything wrong with your mind?" "Are you depressed, 
sad, or afraid?" "Are you unhappy?" "Have you been well 
treated by your family and relatives; by your employers; by 
your neighbors and friends?" In answering these questions the 
patient may betray the existence of hallucinations and delusions 
and the condition of his emotions. 
Orientation.-The patient may be asked to tell his location; 
whether he is in a hospital or a hotel; whether he is with his 
family or friends. He may be asked to identify himself; to give 
his name, age and birthplace. The examiner may ascertain 
whether he is oriented as to time by asking the patient the time 
of day, the day of the week, the month, and the year; whether 
or not he has had his breakfast; how long he has been in the 
place where the examiner finds him. His orientation in regard 
to persons may be ascertained by asking him to give the names 
of persons about him, of his friends and family, of his doctor, 
nurse and ward attendants and others who come in contact with 
him. 
General Memory.-The patient's general memory should be 
tested by asking him about his personal and family life, his 
occupation, marriage and children, the diseases from which he 
has suffered and the injuries he has sustained. 
Special Memory.-Special memory is tested by asking ques- 
tions which are in harmony with the individual's educational METHODS OF EXAMINATION 
275 
advantages and experiences and his nationality. Questions con- 
cerning high school and college subjects should not be asked 
of an individual who has completed only a grammar school 
course. Individuals who have completed grammar school grades 
in the United States may be asked the following questions: Give 
the dates of the beginning and ending of the Civil War. Mention 
four generals of the Civil War, two on the Federal and two on 
the Confederate side. What is the capital of this state? Give 
the capitals of three European countries; the names of the last 
three Presidents; the capital of your native state; the name of 
the Governor of your native state; dates of the Spanish-American 
War. Of a high school or college graduate, questions bearing 
upon his high school or college education may be asked. The 
patient may be given a street number, such as No. 875 Wash- 
ington Street, to remember for five minutes while the examina- 
tion is continued. He should be asked to mention the principal 
items that have appeared in recent daily papers, magazines or 
books. If the individual is a mechanic he may be asked to give 
the names of the parts of the machines with which he works; 
to explain the difference between a steam engine and a gas 
engine. If he is a farmer he may be asked when he plows, 
when he plants certain grains and vegetables, when the crops 
are harvested. If the patient is a musician he may properly be 
questioned about musical composition and the theory of music 
and the names of famous composers. The patient may also be 
given a series of figures to remember, from three to six, such as 
385, 48792, 384861, 54892. 
Stories.-The patient may be told short, simple stories and 
asked to repeat them in his own words. The stories should 
contain ideas which involve simple processes of imagery, rea- 
soning and judgment, and that appeal to the emotions. The 
stories may be printed upon cardboard and the patient allowed 
to read them. After he has read the stories the card is taken 276 
MANUAL OF PSYCHIATRY 
from him and he is asked to repeat them. The classical stories 
are The Cowboy, The Gilded Boy, The Shark Story and The 
Gold Dollar Story. Other stories may be used at the discretion 
of the examiner. jEsop's fables serve the purpose very well. 
The specific stories mentioned are taken from Ziehen and others 
and are extensively used in psychiatric tests in hospitals for the 
insane in Europe and throughout America. These stories contain 
details which are likely to awaken emotional responses, and the 
patient's reaction to them is to be judged in the light of his edu- 
cation and experience. 
1. It is related that at the coronation of one of the popes about three 
hundred years ago a little boy was chosen to act the part of an angel, 
and in order that his appearance might be as gorgeous as possible he 
was covered from head to foot with a coating of gold foil. He was soon 
taken sick and although every known means was employed for his re- 
covery, except the removal of his fatal golden covering, he died in a 
few hours. 
2. A female polar bear with two cubs was pursued by sailors over an ice 
field. She urged her cubs forward by running before them, and, as it 
were, begging them to come on. At last in dread of their capture she 
pushed, then carried and pitched each before her, until they actually 
escaped. The polar bear is a wonderful swimmer and diver. In the cap- 
ture of seals lying on the ice, it dives some distance off and, swimming 
underneath the water, suddenly comes up close to the seals, cutting off 
their retreat to the sea. 
3. A cowboy from Arizona went to San Francisco with his dog which he 
left at a dealer's while he purchased a new suit of clothes. Dressed finely, 
he went to the dog, whistled to him, called him by name and petted him. 
But the dog would have nothing to do with him in his new hat and coat, 
but gave a mournful howl. Coaxing was of no effect, so the cowboy 
went away and donned his old garments, whereupon the dog immediately 
showed his wild joy on seeing his master as he thought he ought to be. 
4. A ship was sailing in the Indian Ocean and all of a sudden a terrific 
storm came up. The second officer of this boat was swept overboard by 
a tremendous wave. The boat was stopped and life boats lowered to 
rescue the officer who had been swept off, but before the crew could 
rescue the drowning man a shark grabbed him and all that was left was 
a streak of blood. 
Catch Questions.-Which is the heavier, a pound of lead, iron 
or feathers? METHODS OF EXAMINATION 
277 
Absurd Statements.1-An unfortunate bicycle rider fell on 
his head and was killed. He was taken to a hospital and they 
fear he will not recover. The police found the body of a young 
girl cut into eighteen pieces. They think she killed herself. A 
man said, "If I were going to kill myself, I would not do so on 
Friday, because Friday is an unlucky day and would cause me 
to have ill luck." There was a railroad accident yesterday, but 
it was not a bad one. The number of deaths is only forty-eight. 
A lady wanted the tail of her pet dog taken off. She was afraid 
it would hurt him, so she decided to have a little piece cut off 
every day. 
Problems.2-A person walking in the forest suddenly stopped 
much frightened, hurried to the nearest policeman, and told him 
that he had just seen hanging from the limb of a tree-(after 
a pause) what? 
My neighbor has been having some strange visitors. He has 
received, one after the other, a doctor, a lawyer, and a priest. 
What has happened at my neighbor's house? 
Some boys were playing ball in the street. The ball rolled 
between the hind legs of a mule and one little boy picked it up. 
Two days later there was a funeral at his house. What 
happened? 
If you were out in a small boat five days from shore and had 
on board a box of gold and a box of bread, which box would you 
throw away if it became necessary to throw one of them over- 
board to prevent the boat from sinking? 
A man who had some potatoes to take to town put them in a 
bag and hung them over the side of his mule. This looked 
strange to him, and the weight all on one side seemed to worry 
the mule, so he filled a bag with stones and hung it over the 
other side. What would you have done under the circumstances? 
1 Portion of the Binet-Simon Scale. 
2 Portion of the Binet-Simon Scale. 278 
MANUAL OF PSYCHIATRY 
Suppose you and a companion were floating at sea in a small 
open boat, having been shipwrecked and left with two buckets 
of fresh drinking water. Several days have passed since the 
accident, and you have consumed all the water in one bucket. 
The other bucket is still full of fresh water, your only supply. 
The empty bucket and full bucket are setting beside you when 
you suddenly discover that your companion's coat is on fire. 
Would you pour the bucket of fresh water over him, or what 
would you do? 
Motor Reactions.-Tapping with a pencil. Handling cards. 
Picking out letters or figures. 
Arithmetical' Problems.-Simple problems in arithmetic, 9 
times 9, 6 times 7, 8 times 8, 24 from 32. How much change 
would you get back if you bought at the grocery store 2 cents 
worth of crackers, 3 cents worth of cheese, 5 cents worth of 
butter and 8 cents worth of sugar, and gave the grocer 25 cents 
in payment? 
Interpretation of Pictures.-Simple pictures may be placed 
before the patient and he may be asked to explain what is 
represented in the picture. His interpretation of the pictures 
will reveal in a rough way the state of his attention, his ability 
to grasp multiple ideas, and the range of his imagination and 
power of imagery. The liveliness of memory is also tested, 
for the picture, no matter how simple, requires the process of 
memory in its interpretation. The response will also indicate 
in some degree the state of comprehension and apperception and 
the integrity of the patient's reasoning powers and the accuracy 
of his judgments. 
Questions in Definition.-The patient may be asked, "What 
is an automobile?" "What is a ship?" "What is a typewriter?" 
"What is the difference between a lion and a lamb; the differ- 
ence between a plant and a mineral; the difference between a METHODS OF EXAMINATION 
279 
man and a plant; a mistake and a falsehood; fact and fancy; 
religion and ethics; shiftlessness and thrift?" 
Sentence Building Tests.-The patient may be asked to 
place the following groups of words into sentences: Man- 
automobile-gasoline-tank. Shoulder-soldier-gun-march- 
camp. Cigarette-match-lighted-smoke. Out-man-went- 
coat-hat-put-on. 
Forward and Backward Association Test.-Give months of 
the year backward; days of the week backward. Repeat 5729 
forward and backward; 64189; 265497. Repeat the seasons of 
the year forward and backward. 
General Information.-The cost of postage stamps. Color 
of stamps. The meaning of holidays-Christmas, Easter, Fourth 
of July. News items. 
Interpretation of Proverbs.-"Make hay while the sun 
shines," "A stitch in time saves nine," "The early bird catches 
the worm," "Too many cooks spoil the soup," "Lies have short 
legs," "Burning the candle at both ends." 
Drawing Test.-Designs are drawn by the examiner, or 
printed cards may be used on which are designs ranging from a 
simple to a fairly complex character. The patient is allowed 
to look at a design for half a minute, and then he is asked to 
draw it from memory. This test is of value in determining the 
integrity of the powers of attention, memory, motor ability, the 
accuracy of movements, and the presence or absence of tremor 
and ataxia. The patient may be asked to assemble the various 
types of jigsaw puzzles or to fit specially shaped blocks into 
form boards of various patterns. 
Supplying Words in a Sentence.-A printed or typewritten 
sentence, in which certain words are left out, is shown to the 
patient, and he is asked to supply the words necessary to com- 
plete the sense of the sentence. The rapidity and accuracy with 280 
MANUAL OF PSYCHIATRY 
which the patient does this test indicates the condition of his 
powers of perception and apprehension. 
Attention Tests.-A series of numbers or letters is read to 
the patient at the rate of two per minute, and he is asked to 
make a tally each time a specified number or letter is read. 
Patients who are distracted or who show variable moods of 
attention will fail in this test. 
Tapping Test.-Patient is asked to make as many dots upon 
a paper with a pencil as is possible within, say, ten seconds. 
This test shows the degree of psychomotor retardation and lack 
of attention. 
Syllogisms.-These tests are of value in determining the at- 
tention, apperception and reasoning power of the patient. He 
may be given the following syllogisms and asked whether the 
conclusions are correct or incorrect, and the reasons for his 
answers: 
Bad men are brave. George Washington was a brave man, therefore 
George Washington was a bad man. 
All crystals are salty. Sugar is a crystal, therefore sugar is salty. 
Ethical Conceptions.-Which is the worse, to lie or to steal? 
Why do you love your parents? What would you do if you saw 
a person drop a ten-dollar bill? Why should one pay his debts? 
What would you do if someone accidentally struck you? What 
occupation do you prefer, and why? Explain the Golden Rule. 
Psychoanalysis.-Psychoanalysis, as the term indicates, is 
the analysis or dissection of the content of consciousness by the 
methods of psychology. 
The hidden source of the patient's mental trouble may be a 
complex which gives rise to a group of symptoms which do not 
in any way bear an apparent relationship to the mental symp- 
toms manifested. Only the barest outlines of the methods of 
the technique of psychoanalysis can be given here, and for METHODS OF EXAMINATION 
281 
greater elaboration the student is advised to consult specific 
texts upon this subject. 
Free Word Association Method.-The examiner should sit 
at the head of the patient, who is allowed to recline upon a 
couch or reclining chair in a quiet, slightly darkened room. No 
third person should be present at the time of these examinations. 
All distracting objects should be removed from the room to 
prevent the possibility of the patient's thoughts straying to 
extraneous objects, such as chairs, or pictures upon the wall. 
The patient's face may be covered with a handkerchief. It goes 
without saying that the physician must enjoy the absolute confi- 
dence of the patient. All elements of fear and restraint should 
be eliminated. 
When the situation just described has been effected, the patient 
is instructed to discuss, freely and at length, any subject or 
thoughts that may come into his mind, without any mental 
reservation, secrecy or modification whatsoever. The thoughts 
or ideas that come to the patient's mind may seem trivial, 
worthless and not related to his trouble, but they should be 
freely told to the physician, as they may shed an abundance of 
light on a repressed, painful complex that the patient may have. 
The ideas that pass through a patient's consciousness may be 
unrolled as a panorama to the physician just in the manner that 
a picture film is unwound. When the free word association test 
is completed, the method of limited word association test is 
employed. 
Limited Word Association Test.-A group of familiar 
words, ranging from fifty to one hundred, consisting of nouns, 
adverbs, adjectives and verbs mingled indiscriminately, is read 
to the patient, one word at a time, in a neutral manner. The 
patient is asked to say the first word or words that may come 
into his mind after the stimulus word is given. He is not to 
make any effort to find any particular word or words to suit the 282 
MANUAL OF PSYCHIATRY 
word that has been given, but is to say just whatever comes into 
his consciousness. It is often well for the examiner to illustrate 
in advance of the test by using a few words which do not occur 
in the list. The time that elapses between the giving of the 
stimulation word and the reaction word of the patient is meas- 
ured by a stop watch marking fifths of a second. These words 
which have a decided emotional value will cause a delayed 
response. The greater the delay, the greater the value of the 
stimulus word. We often find that the emotional reaction that 
follows any given word may be spread to the next two or three 
words, and the patient may give evidence of his emotional 
reaction by a flushing or blanching of the face, by an uneasy 
gesture, or possibly by glancing at the examiner. After the 
stimulus words have been given, the test may be repeated, careful 
attention being paid to see whether the same words produce the 
same reaction time. 
Illustration 
Reaction Word 
Dwelling 
Mother 
John 
Disappointment 
Betrayed 
Stimulus Word 
House 
Home 
Lover 
Love 
Trust 
Time (Seconds) 
3 
8 
10 
15 
30 
In this illustration the word house is promptly responded to 
and the reaction word indicates no particular emotional activity, 
while in contrast the words lover, love and trust are followed by 
reaction words after increasingly long intervals and the reaction 
words are quite significant and suggest the existence of a painful 
complex of a sexual character, such as is often found in hysteria. 
After the test has been given a second time, the examiner may 
use the words giving the longest reaction time, and note the 
reaction time as before. When the words which have the greatest 
emotional value have been discovered and carefully studied by 
the psychiatrist, the key to the patient's complex will very likely METHODS OF EXAMINATION 
283 
be revealed. The following is a group of words that may be 
used in this test, although any group of words may be used, at 
the examiner's discretion: 
Mother 
Father 
Sister 
Lover 
Sweetheart 
Pain 
Man 
Woman 
House 
Love 
Fear 
Hate 
Home 
Glad 
Bitter 
Sweet 
Beautiful 
Sad 
Cry 
Depression 
Kiss 
House 
Happiness 
Sickness 
Evil 
Marriage 
Baby 
Children 
Disappointment 
Mockery 
Patriotism 
Country 
Flag 
Traitor 
Amorous 
Success 
Failure 
It is held by various authorities on the subject of psycho- 
analysis that the patient unburdens his mind of painful ideas, 
or relieves himself by the method of mental catharsis and 
uncovers and lays bare past experiences which he may have 
forgotten and pushed into the unconscious, and to which he 
may have attached at the time of their happening, little or 
excessive importance. Certain experiences in his life may have 
been painful and distressing; they may have been associated 
with ideas of sinfulness, especially as they relate to the conven- 
tional ideas of sex, and may have been abhorrent to the patient. 
After the examiner has discovered the painful, submerged com- 
plex, he is in a position to explain to the patient the needlessness 
of his fears, and to show him that he has attached, in some 
instances, undue importance to ideas that he may have regarded 
as sinful. With the complex uncovered, the physician is in a 
position to instruct his patient as to the proper mode of mental 
life-to give him rational advice about his mental conflicts and 
troubles-to assist him in making better mental and social 
adjustment to his environment. The Catholic Church has long 
known the value of the method of mental catharsis, and has MANUAL OF PSYCHIATRY 
284 
used it in the rite of the confessional. The study of dreams 
often has a very great value in the practice of psychoanalysis, 
for in them painful and repressed ideas are expressed in more 
or less disguised forms. When dreams are analyzed they will 
be found to have greater significance than is due them as the 
mere result of a disordered digestion due to indiscretions at the 
evening meal. 
The success of attempts at psychoanalysis largely rests with 
the skill of the psychiatrist and his insight into the patient's 
condition. The examiner must not always expect to uncover the 
source of the patient's trouble in one seance, for often quite a 
number of seances are necessary. CHAPTER XXIII 
BINET-SIMON SCALE OF INTELLIGENCE TESTS 
This group of tests was devised and standardized in 1905 in 
Paris, by Binet and Simon, for the purpose of measuring the 
intelligence level of individuals. These tests are now used 
throughout America, in public schools, psychopathic clinics, 
prisons, hospitals for the insane and institutions for the feeble- 
minded. Several revisions of the tests have been made to meet 
the needs encountered in America in their application and to 
correct the various errors that existed in their original forms. 
Quite a number of modifications have been made and none is 
free from criticism, but the one now most generally used in the 
United States is the Stanford revision devised by Terman, and 
this modification will be taken as an example of these tests. 
When these tests were first introduced it was held by over- 
enthusiastic examiners that the methods of examining the 
mentally defective would be revolutionized, for they held that 
by these tests the intelligence could be mathematically and 
accurately measured. Much harm was done because this 
so-called scale of intelligence was promiscuously applied by 
many who were unqualified to use it and because the errors in 
it were not recognized. 
These tests have a relative value in determining to an approxi- 
mate degree the mental level of a person, but they should be 
supplemented by careful neuropsychiatric examination lest very 
serious errors be made. The performance of these tests depends 
to a great degree upon normal hearing and normal vision. The 
tests do not take into account language difficulties or the emo- 
285 286 
MANUAL OF PSYCHIATRY 
tional states of either the examiner or the patient, all of which 
are very serious elements of an examination. It has been the 
author's personal experience to see persons suffering from the 
essential psychoses, states of dementia and diseases of the 
endocrine glands, labeled mentally retarded and feeble- 
minded by psychologists of repute but without training in 
pathology or psychiatry. These tests are no more to be de- 
pended upon alone than is a reading of a clinical thermometer 
or a single blood test in physical diagnosis. In conjunction with 
the standard neuropsychiatric tests they are useful to a degree, 
as are other single tests or groups of tests, and their limitations 
are always to be borne in mind. 
METHOD OF APPLYING BINET-SIMON TESTS 
The test should be performed in a quiet, simply furnished 
room where the child's or patient's mind is not likely to be 
distracted, or diverted by anything unusual. On the examining 
table, at which are seated the patient and the physician, there 
should be no articles except those used in the performance of 
the test. 
The patient's confidence should be gained, his fright relieved, 
if present, so that the patient may be in a comfortable frame 
of mind during the examination. The attitude of the examiner 
should be friendly, but he should not indicate in any manner any 
displeasure or judgment concerning the patient's answers to 
questions. The purpose of the test is to measure the child's 
intelligence and not to instruct him. 
Any method that is satisfactory to the physician may be used 
in recording the results of the patient's answers. The following 
one has been used by the author: The plus sign (+) indicates 
that the answer is correct; the minus sign (-), that the patient 
has remained silent; the zero sign (0), that the answer is incor- BINET-SIMON SCALE OF INTELLIGENCE TESTS 
287 
rect; the question-mark sign (?), that the answer is doubtful; 
the minus question-mark signs (-?), that the doubtful answer 
is nearer failure than success; the plus question-mark signs 
(+?), that the answer is nearer success than failure. 
The tests should be begun by giving the child the mental test 
corresponding to his chronological age. If this test is answered 
correctly, continue with the next higher one, and so on. A child 
may be said to have the mental level at which he passes all 
tests correctly. The mental level may be raised by giving credit 
for two to four months for each individual test the child answers 
correctly in any group above the highest group of tests where 
he has answered all correctly. 
If the child fails at the test corresponding to his chronological 
age, the tests immediately below this age should be tried. 
Inability to answer questions of the test corresponding to the 
chronological age do not necessarily indicate mental enfeeble- 
ment. The child is not to be considered mentally defective 
unless the defect shows at least three years' reduction below the 
chronological age. 
It must be remembered that the score resulting from the Binet 
test is often misleading, particularly if the child is given credit 
for passing any test above the year in which he passes all tests. 
For example, the ten-year-old passes completely only the eight- 
year tests, but because of a particular ability in memory is able 
to successfully complete test No. 2 in 10 (drawing designs from 
memory), test 4 in 12 (memory of numbers), test 4 in 14 
(changing the clock hands), tests 2 and 4 in the 16-year test 
(enclosed boxes and code tests), making a total score of approxi- 
mately twenty points. This, added to his score at eight years, 
brings him almost up to his chronological age. Actually, he does 
not approach this in any particular, except his ability to repro- 
duce images-a minor part of intelligence. 288 
MANUAL OF PSYCHIATRY 
Average Normal Psychological Level of Children at 
Three Years of Age 
1. The child is asked to locate his nose, his eyes, his mouth, 
his hair. 
2. The child has a picture placed before him and is to 
enumerate the details. The pictures used by Terman are: a 
mother and child in a Dutch home; two Indians and a man and 
woman in a canoe; a group of men in front of a post-office 
reading a newspaper; a colonial room in which there is a man 
leaving and a woman who is weeping. 
3. He is asked to repeat correctly a sentence containing six 
to seven syllables, as "I have a little dog," "The dog runs after 
the cat." 
4. The child is asked his family name. 
1. In answering the first question, the child shows evidence 
of comprehension and understanding of the words if he merely 
points to the portions of the face referred to in the question. 
2. A child of this mental level can usually recognize and point 
out the chief components of the picture. He usually fails to see 
the action indicated. 
3. A normal child of three years can repeat words or sentences 
containing six to seven syllables. This is no indication that he 
understands what he repeats, but the normal child of two or 
three years is accustomed to imitate. High-grade idiots and 
lowest grade imbeciles do not acquire much facility in the repeti- 
tion of language which they hear. 
4. The child should know his name at this age. 
Average Normal Psychological Level of Children 
at Four Years of Age 
1. The child is asked to compare the length of two lines. 
2. Counting of coins. Four pennies are placed in a row and BINET-SIMON SCALE OF INTELLIGENCE TESTS 
289 
the child counts them, using his fingers as he makes the count. 
3. The copying of a square from a model which has a diameter 
of three or four centimeters. This drawing is made in pencil. 
4. He should repeat four digits, as: 4- 7 - 3 - 9. 
1. The lines drawn for comparison should be parallel and 
should differ at least three centimeters in length. Prolonged 
hesitation in making the judgment is to be counted as failure. 
2. No error is allowed in the counting test. 
3. If the child can make a drawing which at all resembles a 
square, the test is passed. 
4. The child should repeat correctly one of the series of four 
digits. The numbers are given to the child slowly and distinctly. 
Average Normal Psychological Level of Children 
at Five Years of Age 
1. Comparison of weights. The weights used are blocks of 
wood of the same appearance, one of which weighs three grams 
and the other fifteen grams. 
2. Recognition of four colors. 
3. Giving definitions in terms of use. "What is a chair?" 
also horse, fork, doll, pencil and table. 
4. The execution of three different small acts. "Here's a key. 
I want you to put it on that chair over there; then I want you 
to shut (or open) that door, and then bring me the box which 
you see over there. Do you understand? Be sure to get it right. 
First, put the key on the chair, then shut (open) the door, then 
bring me the box. Go ahead." 
1. Three trials are given, two of which must be correct. After 
the first trial the position of the weights is reversed. At the third 
trial the position is the same as in the first trial. This is neces- 290 
MANUAL OF PSYCHIATRY 
sary because of the stereotyped behavior which some children 
exhibit of choosing always the block on a certain side. 
2. The colors (red, blue, green and yellow) used in this test 
are printed on a cardboard. In performing the test the exam- 
iner should point to the color and ask, "What is the name of that 
color?" The test is passed if all the colors are named correctly 
and without marked uncertainty. 
3. If a child correctly defines four objects out of the six, he 
is credited with having passed the test. Most children of five 
oi six years will define the objects in terms of use. Two-thirds 
of eight-year-old children will give definitions superior to use; 
that is, by description, by giving the class to which it belongs, 
what it is made of, etc. 
4. After the child has been told to perform the simple com- 
mands he should not be given any help or suggestion. This is 
a test of memory of a type that is needed in every-day life. 
Average Normal Psychological Level of Children 
at Six Years of Age 
1. Right hand; left ear; right eye. Examiner says to child, 
"Show me your right hand," etc. 
2. Mutilated pictures. 
3. Naming four coins. 
4. Distinction of time. Question: "Is this morning or evening?" 
1. In answer to these directions three sorts of responses are 
most frequently found. There is confusion by the child of the 
right and left. If he is a right-handed child he may show the 
right hand because of habit. He often shows the right ear. 
Again, the child may not be sure of his knowledge of right and 
left. He often puts forth the right hand and then touches the 
right ear, but corrects himself. The last response is counted in 
all cases of double responses. If the child cannot make it plain BINET-SIMON SCALE OF INTELLIGENCE TESTS 
291 
that he knows which is right or left, he must be regarded as 
having failed. At the four-year level children cannot ordinarily 
distinguish between right and left. Normal children of six years 
succeed with this test. Imbeciles below the middle-grade very 
rarely pass this test. 
2. In this test the faces of the women are without eyes, mouth 
or nose, and the female figure is without arms. The child should 
tell correctly, in three of the four problems, what is missing. 
3. The coins used are a nickel, a penny, a quarter, and a dime. 
The child should name the coin or give its value. Three correct 
responses are necessary for the test to be passed. 
4. Many children are inclined to answer the latter of two 
alternatives. It is well, then, if it is morning, to put the question, 
"Is this morning or afternoon?" or if it is afternoon, to say, "Is 
this afternoon or morning?" 
Average Normal Psychological Level of Children 
at Seven Years of Age 
1. Description of pictures as to characters and situations. 
2. He should repeat five digits. 
3. The comparison of three sets of objects from memory; the 
difference between a fly and a butterfly; between wood and glass; 
between a stone and an egg. 
4. Copying a diamond from a model given. 
5. Naming the days of the week. 
1. The child should describe the situations and not merely 
enumerate the objects in the picture. 
2. The child should repeat correctly one of the series of five 
digits. 
3. This test is passed if the real difference is given in two 
out of the three comparisons. It is not necessary for the differ- 
ence to be an important one, but it must be a real difference. 292 
MANUAL OF PSYCHIATRY 
4. Two of the three drawings must be made in approximately 
the correct position. The diagonals must not be reversed. Size 
is disregarded. 
5. The days of the week must be named in the correct order, 
without errors, in fifteen seconds. 
Average Normal Psychological Level of Children 
at Eight Years of Age 
1. Counting backwards from twenty to one. 
2. Comprehension questions such as: "What's the thing for 
you to do when you have broken something which belongs to 
someone else?" 
3. Giving similarities. 
4. Definitions of twenty words. 
1. This test must be done in forty seconds. Only one error 
is allowable. 
2. Two of the three questions must be comprehended and a 
reasonably sensible answer given, such as: "Pay for it," "Apolo- 
gize," etc. 
3. The following things are to be compared: (a) wood and 
coal, (b) an apple and a peach, (c) iron and silver, (d) a ship 
and an automobile. A likeness must be given in two out of four 
comparisons. Any likeness, whether trivial or important, is 
acceptable. 
4. The definition is regarded as correct if the right meaning 
of the word is given, whether this meaning is the most common 
one or whether it is the original or a derived meaning. 
Average Normal Psychological Level of Children 
at Nine Years of Age 
1. Giving the date. 
2. Grouping of weights in proper order. BINET-SIMON SCALE OF INTELLIGENCE TESTS 
293 
3. Subtracting 4 cents from 10 cents; 12 cents from 15 cents; 
4 cents from 25 cents. 
4. The formation of a sentence, using three words given by 
the examiner. 
1. If the child gives the correct month, day of month, year, 
and day of the week, he is regarded as having passed the test. 
2. Five wooden blocks are used, similar in size and shape but 
so loaded as to have different weights, which are respectively 
3, 6, 9, 12 and 15 grams. These are placed in front of the child 
and he is told to place the weights in a row, beginning with the 
heaviest and placing the others in properly graduated order. 
Three trials are given, two of which must be correct. 
3. The test is passed if two out of three problems are answered 
correctly in 10-15 seconds for each problem. 
4. Three sets of words are given: "Boy, runs, ball," "Work, 
money, men," "Rivers, deserts, lakes." Each set of words is to 
be put into one sentence. Often the child answers by giving three 
single sentences, using each word. No credit is to be given for 
such an answer. 
Average Normal Psychological Level of Children 
at Ten Years of Age 
1. Absurd sentences. 
2. Drawing two designs from memory. 
3. More difficult comprehension questions, such as: "What 
ought you to say when someone asks your opinion about a person 
you don't know very well?" 
4. Form board puzzle. 
1. The sentences contain some absurdity. The examiner should 
explain to the child that the sentences are absurd and let the 
child discover the absurdity. An example of the absurd sentence 294 
MANUAL OF PSYCHIATRY 
is the following: "A man said, 'I know a road from my house 
to the city which is down-hill all the way to the city and down- 
hill all the way back home.' " The absurdity must be detected 
in four out of the five sentences. 
2. Two designs are shown to the child, and he should be given 
the opportunity to examine them for ten seconds. The designs 
are taken away and the child should reproduce them. 
3. Two of the three questions must be comprehended and a 
reasonably sensible answer given for each. 
4. The child is to put the blocks into the frame so that all 
the space is filled up. He must fit the blocks into place three 
times, five minutes being the total amount of time taken for 
all the trials. This makes no demands on language ability and 
is one of the few tests in the scale that gives an index of the 
child's ability to deal with concrete material. 
Average Normal Psychological Level of Children 
at Twelve Years of Age 
1. Definition of abstract words, such as "pity" or "justice." 
2. Disarranged sentences, as: For - the - started - an - we - 
country - early - at - hour. 
3. Interpretation of fables. 
4. Repeating backwards five digits. 
5. Interpretation of the same pictures which were used in 
years three and seven. 
1. If the child expresses the essential idea, even though in very- 
poor English, the answer is to be regarded as correct. Three 
out of the five words must be defined correctly. 
2. For each sentence the child is allowed one minute in which 
to rearrange the words so that they make a good sentence. Two 
out of the three sentences should be correctly rearranged. 
3. Fables teach a moral lesson. The child should discover BINET-SIMON SCALE OF INTELLIGENCE TESTS 
295 
the moral lesson in at least two of the fables and state it in 
general terms. It is a valuable test to see whether the child is 
able to generalize the concrete. 
4. It is much more difficult to repeat a series of digits back- 
wards than in the direct order. It is also less mechanical and 
requires more attention. If the child has success in any one of 
the three series, he passes the test. 
5. Three pictures out of the four must be given an interpre- 
tation which is plausible. For example, in the first picture, "The 
baby has hurt herself and the mother is comforting her." 
Average Normal Psychological Level of Children 
at Fourteen Years of Age 
1. The distinction between a president and a king. 
2. Answering two concrete problems. 
3. Problems in arithmetic such as, "If two pencils cost 5 cents, 
how many pencils can you buy for 50 cents?" 
4. Changing the hands of a clock. 
5. Repeating seven digits forward. 
1. The subject is asked to state three differences between a 
president and a king. This test is psychologically related to 
that of giving differences and similarities but it requires a com- 
parison which is based on essential distinctions rather than on 
unimportant distinctions. 
2. Two out of the three responses must be sensible and plaus- 
ible answers to the problem. Example of the problems: "My 
neighbor has been having queer visitors. First a doctor came 
to his house, then a lawyer, then a minister. What do you think 
happened there?" A correct answer to this would be that a 
man is dying and making a will. 
3. Two out of the three problems should be answered correctly, 
allowing one minute for each. MANUAL OF PSYCHIATRY 
296 
4. Changing the hands of a clock from 6:22 to 4:30; 8:08 to 
1:40; 2:46 to 9:10. The subject must not look at a clock during 
this test. It is a test of the imagination. Two out of the three 
problems must be solved correctly. 
5. The subject should repeat correctly one of the series of 
seven digits. 
Average Normal Psychological Level of Adults 
1. The difference between abstract words. 
2. Problem of the enclosed boxes. 
3. Code. Test words, "Come quickly." 
4. Repeating twenty-eight syllables. 
1. The subject is asked to state the difference between laziness 
and idleness, evolution and revolution, poverty and misery, char- 
acter and reputation. 
2. "You see this box? It has two smaller boxes inside of it, 
and each one of the smaller boxes contains a little, tiny box. 
How many boxes are there, counting the big one?" There are 
three other, similar problems. Three out of the four must be 
passed, allowing thirty seconds for the solution of each problem. 
3. The suggestion to use the code test was made by William 
Healy. The code is not original with him. It was used by the 
Confederate army during the Civil War. The letters of the 
alphabet are represented in the manner suggested in the draw- 
ings below. The code is explained to the subject in detail, and 
a d g 
b e h 
c P i 
< m. ,p 
k. n. .q 
1 o r 
x 
■I 
Example :• 
ezO-rrv© I BINET-SIMON SCALE OF INTELLIGENCE TESTS 
297 
then certain ciphers of the code are shown to him which inter- 
preted mean, "syp," "war." The subject is then asked to write 
a sentence of two words, using this code. This should be done 
in five minutes, with no more than two errors. 
4. This test is passed if one of the three sentences is repeated 
without a single error. 
Average Psychological Level of Superior Adults 
1. Definition of seventy-five words. 
2. Repeating eight digits forward. 
3. Repeating the thought of a passage read aloud to the sub- 
ject. 
4. Repeating seven digits backward. 
1. The subject should be able to define correctly seventy-five 
out of one hundred words. The words vary in difficulty. 
2. The subject should repeat correctly one of the series of 
eight digits. 
3. The test is passed if the subject repeats in reasonably con- 
secutive order the chief ideas in at least one of the selections 
read. 
4. The subject should repeat backward one of the series of 
seven digits. CHAPTER XXIV 
TREATMENT 
In this small volume the subject of treatment can be no more 
than briefly outlined. The general principles of therapeusis are 
applicable to the psychoses as they are to disease in general. The 
subject will be dealt with under three heads, as follows: 
1. Prevention. 
2. Extramural Treatment. 
3. Intramural Treatment. 
Prevention.-The old adage, "An ounce of prevention is 
worth a pound of cure," is beginning to be applied in the treat- 
ment of insanity. Within the last ten years there have come into 
being national, state and local organizations for the study and 
demonstration of facts concerning mental diseases, and these or- 
ganizations are educating the public in regard to matters that 
pertain to insanity and allied subjects, such as mental and so- 
cial hygiene. By means of public lectures and the distribution 
of literature, these organizations are quietly but effectively using 
their influence to remove the stigma that has heretofore attached 
to insanity. They are making the public understand that com- 
mitment to a hospital for the insane is no more disgraceful than 
is admission to a general hospital for the treatment of a physical 
disorder. 
Many persons who suffer from the incipient stages of mental 
disorders shrink from seeking hospital treatment in state in- 
stitutions because, as before stated, the idea of disgrace is at- 
tached to mental disease. The result is that the mental disorders 
of these persons progress to a degree which makes commitment 
298 TREATMENT 
299 
to a state institution an absolute necessity, because of lack of 
care at the proper time. To overcome this evil of delayed treat- 
ment, some states have wisely provided the privilege of voluntary 
commitment to a state hospital for the insane, so that an indi- 
vidual may go there in the incipient stages of his disease and, 
without publicity, receive treatment at the time when thera- 
peutics are most likely to be of benefit. In most states all that 
is required is a certificate of the family physician, to be sub- 
mitted to the superintendent of a state institution, stating that 
the patient who asks for commitment is in need of treatment. 
The applicant signs a statement to the effect that he will abide 
by the rules of the institution so long as he is a patient, and 
that when he desires to be discharged he will give written notice 
in advance (seven or ten days', as the case may be). At the 
end of the time stated, he is permitted to leave the hospital on 
his own responsibility. 
Psychopathic Hospitals.-The advance in modern psychia- 
try and the needs of the social body make it highly desirable 
that there should be established in all large cities or in certain 
definite districts throughout the various states, psychopathic 
hospitals where the acutely insane or mentally sick could be 
taken, classified and treated in the early stages of their disorder. 
From such institutions those who recover after a relatively short 
lapse of time could be returned to their homes or sent to private 
institutions for temporary care, and those whose ills prove to 
be of a chronic nature could be distributed to hospitals and 
colonies for the chronic insane. 
Commitment.-In most of our states the present method of 
committing patients to hospitals for the insane should be cor- 
rected. As a rule, the patient is haled into court as though he 
were a criminal. He is arrested and charged with being insane, 
and is subjected to insults and embarrassment for which there 
is not the slightest reason. It is at once conceded that insanity 300 
MANUAL OF PSYCHIATRY 
is a sociological as well as a medical affair and that the rights 
of society must be carefully protected, but it is also apparent 
that to arrest an individual because he has an illness of the 
brain is just as unreasonable as it would be to arrest a person 
because he was suffering from a delirium due to appendicitis. 
A lay jury, moreover, is in nowise competent to pass upon men- 
tal diseases, yet in many instances juries ignorant of medical 
facts are making decisions as to whether or not insane persons 
should be committed to state hospitals. 
It is gratifying to realize, however, that progress is being made. 
Many courts are now employing medical experts to advise them 
as to whether or not mentally sick persons should be committed 
to state institutions. In course of time no doubt much of the 
red tape and legal procedure will be abolished and the matter of 
commitment will be placed in the hands of medical persons. 
Probably the only legal procedure that will be retained will be 
that which is necessary to protect society and the civil rights 
of the patient. 
Heredity and Eugenics.-The greatest single factor in the 
production of insanity is heredity; fifty to ninety per cent of 
all cases of insanity owe their origin to the direct or indirect 
transmission of insanity, or to the passing on of a predisposi- 
tion from the progenitors to the offspring. This point has been 
discussed under "Causes of Insanity," in Chapter III. So- 
ciety is beginning to learn that mentally defective persons mated 
with mentally defective persons can produce only mentally de- 
fective offspring. The public is not yet ready to receive and 
act upon medical advice to any great extent in the matter of 
marriage. Sterilization, regulation of marriage and the segre- 
gation of the racially unfit is possible in only a very small per- 
centage of instances. A few states have laws concerning these 
matters, but they are by no means adequately enforced. TREATMENT 
301 
Syphilis.-Syphilis is directly and indirectly responsible for 
at least twenty-five per cent of all cases of insanity. Syphilis 
is the direct cause of insanity in the form of general paresis and 
other types of cerebral syphilis, and indirectly by bringing about 
conditions of arteriosclerosis affecting the brain and the cardio- 
vascular-renal systems. Forms of mental defect, such as idiocy, 
imbecility and feeblemindedness, may have their origin in syph- 
ilis. The public is beginning to learn of the widespread effects 
of syphilis and its relation to insanity, and the value of mental 
and social hygiene will be demonstrated within a few years by 
an appreciable reduction in the number of cases of insanity due 
to syphilis. 
Tuberculosis.-Tuberculosis plays a part in the production 
of insanity, since it weakens the human mechanism and makes 
it susceptible to the development of mental diseases. The inter- 
relation of tuberculosis and dementia praecox is well known. 
Drugs.-The chronic use of alcohol, cocaine, morphine and 
other drugs is responsible for many cases of insanity. The gen- 
eral campaign for the education of the public against these po- 
tent factors in the production of mental disease will in a few 
years result in a reduction of the percentage of mental dis- 
orders due to these agencies. 
Heredity, syphilis and drugs are the great triad of contempo- 
raries that fill our hospitals for the insane. The hope of the 
future lies in a reduction of their influence. 
Present Problems.-We, as physicians, must deal with the 
problem as it exists at the present time. The neurotic or psycho- 
pathic child and the individual predisposed to insanity must be 
dealt with as we find them. The neurotic or psychopathic child 
should be early singled out and safeguarded through infancy, 
childhood and adolescence. Proper food and clothing, kindly 
discipline, the teaching of self-control, regulation of work and 
play and limitation of hours of study are necessary if the neu- 302 
MANUAL OF PSYCHIATRY 
rotic child or youth is to be saved from the development of men- 
tal disorders. 
Briefly, physical and mental hygiene are necessary. The 
same general principles of prevention apply to the neuropathic 
or psychopathic adult who has in some way acquired the predis- 
position to the development of mental disorder. 
Extramural Treatment.-Certain mental disorders such as 
temporary delirium, mild states of depression, mild types of de- 
mentia praecox, senile dementia, harmless types of paranoia, 
paranoid states, hysteria and the allied psychoneuroses can in 
many instances and for a while at least, be treated outside of an 
institution, and the knowledge of how to treat these conditions 
in the general practice is essential. In many instances, persons 
have been committed to institutions for the insane while they 
were suffering with delirious states originating before, during 
or after infectious and febrile diseases such as typhoid, influ- 
enza, pneumonia or erysipelas. This should not be found neces- 
sary. The temporary delirium and confused states following 
the use of certain drugs such as alcohol, morphine, cocaine, as- 
pirin or potassium bromide, may occasionally be cared for out- 
side of a hospital under appropriate conditions. No person 
should be committed to an institution for the insane until he has 
been examined by psychiatrists or other physicians competent to 
diagnose and treat mental cases. 
The majority of mental cases will require institutional care. 
The physician is able to treat his patient to better advantage 
away from the influence of relatives, whose anxiety often leads 
to injudicious interference with treatment. When the patient 
is removed from his home he is taken away from the atmosphere 
in which his trouble has developed and from an environment 
about which he may entertain delusional conceptions. The rou- 
tine of an institution has a decidedly beneficial effect upon the 
mentally ill. The safety of the patient and the welfare of others TREATMENT 
303 
often demand that the patient be removed to an institution where 
he can be properly guarded. 
Intramural Treatment.-Just so soon as it is determined that 
the patient cannot be treated at home in a successful manner- 
because he cannot receive the necessary attention, or because he 
is dangerous to himself or others-he should be committed to an 
institution for the insane, either private or public. In such an 
institution the patient will receive custodial care and the neces- 
sary symptomatic treatment called for in his case. 
Delirium.-Delirium incident to febrile and infectious dis- 
eases calls for the isolation of the patient, the employment of 
coolheaded, trained nurses or attendants, the elimination of 
toxins or drugs by way of the emunctory organs, the mainte- 
nance of the patient's strength and the allaying of his delirium, 
confusion or excitement. The patient should be placed by him- 
self in a quiet, darkened room. Liquids should be administered 
in large quantities, together with light, nutritious food. Baths 
should be given freely, having due regard for the patient's 
strength. The temperature should be controlled by sponging, the 
use of ice caps, warm and cold packs, neutral baths, and by medi- 
cation when indicated. It is quite possible in some cases to give 
the patient a prolonged bath ranging from 90° to 95° F. Often 
a wet pack is of great service, but great care must be exercised 
in using this measure because excessive reactions are likely to 
occur if the patient is kept in a pack too long. A cold pack may 
be given to robust patients. A sheet is dipped in luke warm 
water; the arms are placed at the sides; the sheet is then care- 
fully wrapped about the body and around this is folded one 
moist and one dry blanket. An ice cap is applied to the pa- 
tient's head. The patient should not remain in this pack more 
than an hour. The pulse and temperature should be taken each 
ten minutes and the greatest care and closest observation should 
be given to prevent exhaustion. 304 
MANUAL OF PSYCHIATRY 
In excited cases, preliminary to this treatment a mild hypnotic 
may be given an hour or two before the patient is put into the 
pack. Small doses of bromide, veronal, trianol, sulphonal or 
adalin may be used. In very excited cases one 1/100 of a grain 
of hyoscine or % grain of morphine may be employed. In all 
cases of delirium and excitement the heart should receive care- 
ful attention. 
In ambulatory cases where excitement or delirium prevails, 
hot and cold packs may be given at stated intervals. Hydro- 
therapy may be employed in any of its forms, such as prolonged 
baths, continuous baths, sitz baths, shower, needle, fan and spray 
baths. Spinal and Scotch douches may be used, regulated to 
suit the needs of the patient. Following any form of hydro- 
therapy the patient should be given a vigorous rub, a glass of 
milk, cocoa or other hot liquid, a mild sedative, if indicated, and 
put to bed. 
Hydrotherapy is to be employed in any of the psychoses where 
excitement is to be overcome and rest secured. As a rule there 
is a general improvement in the bodily nutrition following the 
use of hydrotherapy. This form of treatment is of particular 
value in preventing and relieving decubitus. 
Use of Cathartics.-The theory that autointoxication is the 
basis of many mental diseases has no doubt been overworked. 
However, constipation is undoubtedly the bane of mankind, 
sane or insane, and in many instances the correction of this con- 
dition in the treatment of the insane has been followed by splen- 
did results. The inaccurate and excessive use of cathartics is 
of course to be condemned. The author has found that a vigor- 
ous dose of castor oil, or three grains of calomel, or frequent 
colonic flushings, has relieved irritability, insomnia, lassitude, 
malaise and anorexia, symptoms that are so frequently exhibited 
by the insane. The use of saline laxatives such as seidlitz pow- 
ders, citrate of magnesia, Epsom salts and other similar cathar- TREATMENT 
305 
tics is often attended by excellent results. Elimination, often 
repeated, renders incalculable service in treating morbid mental 
states. 
Liquid petrolatum, given twice a day, in the afternoon and 
evening, is a remedy that is quite satisfactory in regulating the 
bowels. Free elimination by way of the kidneys is obtained by 
the use of cooling and mildly acidulated drinks such as lemon- 
ade and orangeade. 
Sleep.-It is essential that a person suffering from a mental 
disorder procure as much natural sleep as possible. It often 
comes following a prolonged warm bath, a salt glow, a gentle 
massage, a moderate amount of exercise a few hours before bed- 
time, or a ride in the open air. A glass of hot milk or hot water 
just before going to bed is often sufficient to produce sleep. So 
long as drugs can be avoided in the securing of sleep, they should 
not be used. However, many cases will be encountered which 
will require the use of drugs, and the choice of these agents must 
be governed by the condition of the patient and the degree of his 
insomnia. Veronal, trianol, sulphonal, adalin, chloral hydrate 
and paraldehyde may be used, according to the indications at 
hand. When the habit of insomnia has been thoroughly es- 
tablished and the condition exists as more or less of a bugaboo 
to the patient, these sleep producing drugs may be used over a 
sufficient length of time to break the habit and dispel the fear 
that attends it. Psychotherapy is always to be used in con- 
junction with these drugs, and the practice of proper suggestions 
will go a long way toward preventing the establishment of the 
habit of dependence upon them. Placebos may be used, alter- 
nating with the hypnotic drugs. These somnofacient drugs are 
to be discontinued so soon as it can be safely done. Cases of 
insomnia due to pain are more difficult to handle, and occasional 
doses of morphine or some other derivative of opium may be 
used, and in cases of violent frenzy and profound suicidal ten- 306 
MANUAL OF PSYCHIATRY 
dency it sometimes requires the use of morphine, opium or 
hyoscine to allay and prevent mental distress. Caution, 
is the watchword in using these agents. 
Tonic Medication.-In the majority of instances a patient 
suffering from a mental disorder is in need of tonic medication. 
We find conditions of anorexia, lassitude and general debility, 
states of secondary anemia which require for their relief various 
bitter tonics, elixir of iron, quinine and strychnine, Blaud's pills, 
cacodylate of iron, Basham's mixture, the hypophosphites and 
the various preparations of malt. Whenever tonics are needed 
the jaded appetite must be stimulated by the employment of egg 
nogs, milk punch, and daintily prepared and appetizing foods. 
Forced Feeding.-One of the most annoying symptoms 
exhibited by the insane is the refusal to take food. The de- 
pressed patient, in particular, often refuses his food. Occasion- 
ally a little persuasion will induce the patient to eat. He will 
frequently swallow milk if the cup is put to his lips, or will eat 
if food is placed in his mouth. In many cases, however, a 
patient cannot be prevailed upon to take food at all. If the 
patient is in a fair state of physical health and is well nourished, 
it may be well to allow him to refuse his food for at least three 
days; hunger may induce him to eat. If it does not, resort must 
be had to forced feeding. There are several methods but the only 
one deserving mention is that of feeding by the use of the or- 
dinary stomach tube, which is introduced into the esophagus 
through the mouth by way of the nose. In attempting to intro- 
duce the stomach tube through the mouth it must be borne in 
mind that the patient may energetically resist; he may clench 
his teeth and bite the tube or the finger of the physician. The 
better plan is to pass the tube through the patient's nose, first 
ascertaining whether or not there are any obstructions. The 
physician should have two nurses in attendance when resorting 
to this manner of feeding. The patient should be placed in a TREATMENT 
307 
chair in an upright position, or if it is necessary he may lie upon 
his bed with his back and head raised on a back rest or on 
pillows. In either case the patient's arms and legs should be 
gently but firmly restrained to prevent struggling. The nostrils 
should be cleansed with absorbent cotton and lubricated by the 
application of petrolatum. The operator should stand behind 
the patient and hold the patient's head firmly with his left arm 
and hand. The tube should be carefully, gently and slowly intro- 
duced along the floor of the nose. If no obstruction is met, the 
tube should be pushed backward. It will glide along the posterior 
wall of the pharynx and pass down into the esophagus and thence 
into the stomach. The operator sould be careful not to pass the 
tube into the larynx. If this should happen the air will be 
heard rushing in and out of the tube and the patient will strangle. 
To prevent such a mishap it is well to tip the head slightly for- 
ward as the tube slips down into the esophagus. The patient 
should not be permitted to throw his head backward while the 
tube is being inserted, as this may cause it to pass forward into 
the mouth. After the tube has been introduced the physician 
should wait for a few seconds to see that there is no interference 
with the breathing. Occasionally there is a slight rush of air 
from the stomach through the tube, which may be mistaken for 
air from the larynx. The physician may hold his ear to the 
funnel of the tube after it has been introduced into the stomach, 
to assure himself that the tube is in the proper place. 
After the tube is passed, a pint and a half of milk, with eggs 
or other forms of liquid food, to which may be added medicines 
if necessary, may be poured very slowly into the rubber funnel. 
The funnel should never be allowed to empty itself entirely 
before the feeding is finished, for if this is permitted air will be 
introduced into the stomach. The amount of food may be in- 
creased to meet the needs of the patient. When the tube is with- 
drawn it should be tightly pinched so that no liquid leaks from 308 
MANUAL OF PSYCHIATRY 
it as it passes the larynx. Patients should be fed night and 
morning. This manner of feeding may be continued over long 
periods of time without the slightest difficulty if proper care is 
exercised. 
It is well to remember that paretic patients are likely to have 
anesthesia of the posterior nares, the pharynx and the larynx, 
and that the tube may pass into the larynx for a short distance 
without any symptoms whatever. Patients having marked 
forms of heart disease or pathological conditions of the esopha- 
gus and cardia should not be fed in this manner. 
Focal Infections and Surgical Conditions.-Up to within 
the last five years, insufficient attention has been paid to focal 
infections and surgical conditions in the insane. The overwhelm- 
ing press of work in state institutions has very materially hin- 
dered physicians in such institutions from giving this subject 
more careful attention. A survey of every insane patient should 
be made with a view to discovering whether or not he has hidden 
foci of infection or whether there exist surgical conditions such as 
a sliding, uncomfortable hernia, or lacerations of the perineum 
and the uterus in female patients, which upset and disorder the 
physical economy and indirectly disturb the mental integrity. 
While academic questions concerning the relation of focal infec- 
tions to the development of insanity are still being debated, those 
who labor earnestly to remove these pathological conditions from 
insane patients are in many instances rewarded by the recovery 
of their patients. At any rate, whether a patient is insane or not, 
he should receive necessary surgical and medical attention. No 
argument can be brought to bear to refute this statement. 
Gastrointestinal Tract.-Careful examination of the gastro- 
intestinal tract in insane patients often reveals carious or im- 
pacted teeth. Or the tonsils may be enormously large and filled 
with pus and other pathological debris, or they may be very 
small and buried beneath the pillars, but nevertheless pouring in- TREATMENT 
309 
fection into the general system. Reddened, inflamed and purplish 
tonsils are decidedly suspicious of diseased conditions. 
Occasionally it is necessary to examine the stomach contents 
by the Rehfuss fractional method. Such an examination may 
disclose the presence of virulent bacteria in the stomach con- 
tents. Duodenal ulcer, a diseased gall bladder, chronic enteritis 
or chronic appendicitis, or hemorrhoids, fissures or ulcerated con- 
ditions about the rectum, may be found upon careful examina- 
tion. The patient is entitled to relief from these conditions, and 
it is always possible that relief from them may bring about a 
recovery from his psychosis. 
Genital Organs.-All diseased conditions of the genital organs 
should be corrected and to this end a careful examination must 
be made of the external genitalia, the vagina, the ovaries, the 
tubes and the body, neck and cervix of the uterus. In the male 
the condition of the external genitals, the seminal vesicles and 
the prostate gland should receive attention. 
Sinuses.-The frontal, ethmoidal, sphenoidal sinuses and 
mastoidal cells may prove to be sources of virulent infection, as 
may the antrum of Highmore. All pathological conditions of 
these parts are to be remedied. 
Vaccine and Serum Therapy.-Vaccine and serum therapy 
are to be used as indicated in the process of detoxication of the 
patient. The author has found vaccine therapy in the form of 
autogenous vaccines and serums of particular value in a num- 
ber of cases of dementia praecox. In the preparation of vaccines 
and serums the results are likely to be disappointing unless it is 
borne in mind that the patient may be suffering from a number 
of strains of one or more types of bacteria. 
Endocrine Therapy.-The mental integrity is very largely 
dependent, if not wholly so, upon the proper functioning of the 
physiological processes, and the endocrine system plays an enor- 
mous part in the metabolic functions, growth and development of 310 
MANUAL OF PSYCHIATRY 
the body and central nervous system. The pineal, pituitary, 
thyroid, thymus and gonadal glands play an enormous role in 
regulating the mechanism of growth, as has been abundantly 
proved by animal experimentation and clinical experience. 
It follows that disturbances of the endocrine functions must 
have, at times, at least, very definite and decided detrimental 
effects upon the mental state. The exact relation between dys- 
function of the ductless glands and the developmnt of insanity 
is not clear. Herein lies a fruitful field for research. In the 
developmental defects and mental disorders of retarded children, 
endocrine imbalance is prominently manifested, especially by 
the physical stigmata. 
The mental disturbances which often attend puberty, adoles- 
cence, pregnancy, childbirth and the menopause, have an inti- 
mate relationship with the disturbances of the function of the 
ductless glands. 
The nervous system is extremely sensitive to disturbances of 
the endocrine functions and excessive elaboration of the internal 
secretion of the thyroid gland produces the well-known mental 
and nervous symptoms of hyperthyroidism. The failure in child- 
hood of the thyroid gland to produce its internal secretion is 
followed by the development of the classical symptoms of cretin- 
ism. Loss of the normal thyroid secretion in an adult gives us 
the well-defined picture of myxoedema. 
The ductless glands of the body respond to temporary and con- 
tinued disturbance of the emotions. Jealousy, anger and fear, 
acting through the sympathetic nervous system, produce states 
of endocrine imbalance. When these psychogenetic factors exert 
their influence over long periods of time, actual structural 
change takes place in the glands of the endocrine chain. It has 
been established also that focal infections exert an untoward 
influence upon the ductless glands. When these focal infections 
have been removed the endocrine balance is often restored. TREATMENT 
311 
At the present time organo-therapy is in the empiric and ex- 
perimental stage. In many cases endocrine therapy appears not 
to have the slightest value in the treatment of mental disorder. 
In others, brilliant results have followed its use. The author 
has used organo-therapy in dementia praecox, involutional 
melancholia, and psychotic disturbances attending the meno- 
pause, with very decided benefit in a number of cases. 
The present state of our knowledge on this subject leads one 
to believe that pluriglandular therapy is superior to the mono- 
glandular forms of treatment. While in any given case the 
symptoms of glandular disturbance may point almost specifically 
to disturbance of a single gland, yet it has been found that the 
use of the single extractive is not as effective as when combina- 
tions of synergic extracts are used. The physician, however, is 
to be guided by his own experience in these matters. There is 
no occasion to view the methods of glandular therapy in a spirit 
of disapproval and in a nihilistic attitude. On the contrary, an 
open mind is to be maintained concerning the use of these sub- 
stances in the practice of psychiatry. 
Psychotherapy.-The mechanism of the influence and effect 
of the mind upon the body is still a mystery. Sensation is trans- 
formed into thought and thought initiates muscular action; 
thought likewise, through the emotions, modifies the bodily secre- 
tions in some mysterious fashion. 
Mental suggestion as a mode of healing is as old as the prac- 
tice of medicine itself. The modern conception of suggestive 
therapeutics embraces the idea that it is a definite procedure 
based upon the laws of psychology and physiology and not 
merely the indeliberate, unconscious suggestion and power of 
personality that a physician may exert upon his patients in the 
treatment of their disorders. 
Briefly, psychotherapy may be defined as the deliberate use 
of the power of benevolent suggestion in the treatment of dis- 312 
MANUAL OF PSYCHIATRY 
ease. Psychotherapy cannot affect organic disease of the brain 
or the essential insanities directly, but it can help the patients 
suffering with these disorders to assume the attitude of mind 
which will marshal their mental and physical powers in the 
fight against disease. 
The methods of psychoanalysis are to be used in the treat- 
ment of the insane in a very careful manner. Psychoanalysis 
is of no greater benefit to the patient suffering from mental dis- 
order than is the physician's sympathetic understanding of the 
patient's disorder and the application of direct suggestion to 
the relief of these conditions. Yet psychoanalysis can occasion- 
ally remove the excessive emotional value that the patient has 
attached to his worries, fears and delusions. For this reason it 
is of great value in certain instances. In the psychoneuroses 
psychoanalysis is of value when cautiously and carefully em- 
ployed. Unwisely used, it is decidedly harmful and often leads 
to morbid introspection and self-analysis. 
Recreation and Occupation.-Occupational and recreational 
therapy are now playing important parts in the treatment of 
the insane. The maniacal patient's useless expenditure of energy 
can often be diverted into useful channels of work, or into play, 
and the brooding, melancholic and delusional patient finds relief, 
at times, from his painful mental reveries in pleasurable activ- 
ities. 
In conclusion, the treatment of the insane can be summarized 
by saying that each insane patient is to be studied individually 
-he is not to be given mass treatment. Physically he is to be 
reconstructed; focal infections and surgical conditions are to be 
removed and remedied, disorders of body metabolism are to be 
corrected, constructive and tonic medication are to be employed 
when indicated, and psychotherapy is to be used as may be 
necessary. Merely to label an individual's psychosis is un- 
availing. The patient's mental mechanism must be understood 
and treatment administered accordingly. CHAPTER XXV 
RELATIONSHIP OF INSANITY TO CRIME 
There is probably no type of crime that has not been com- 
mitted by insane, persons, and often the intrinsic acts of crime 
are not to be distinguished from crimes committed by normal 
persons, except by the underlying motives which prompted their 
commission. 
The overt act committed by the mentally alienated usually 
carries with it tangible evidence of mental disease. The at- 
tending circumstances in such instances likewise are marked by 
the distinguishing characteristics of mental unsoundness. 
The dangerous assaults committed by the insane epileptic in 
the furore and frenzy of an epileptic automatism, the violent acts 
perpetrated in the agitation and delirium caused by alcoholism 
or other narcotic drugs are so labeled as to leave but little room 
for doubt as to the mental status of the persons performing 
them. 
Impulsiveness is a symptom of insanity which is often shown 
by crime. The insane often react in a very sudden and precipit- 
ous manner to overpowering obsessions and imperative ideas. 
The very lack of forethought, the suddenness and violence of 
certain criminal acts point to the nature of their origin. Very 
often the misdemeanors are so absolutely silly, ludicrous and 
devoid of any purpose whatsoever that they could not have been 
committed by any individual than one suffering from some form 
of dementia. We are at once suspicious of the mental integrity 
of the person who commits crime openly and boasts of it as an 
accomplishment. 
The crimes of some types of insanity are so characteristic that 
313 314 
MANUAL OF PSYCHIATRY 
the misdemeanor committed at once suggests the form of in- 
sanity with which its perpetrator is suffering, yet, on the other 
hand, the mentally unbalanced may use such deliberateness, 
such skill in execution, such a degree of apparent reasonable- 
ness, that all except qualified alienists are ready to condemn 
them as willful and perfectly sane criminals. An insane criminal 
may be so cunning as to hide his crime and seek to evade re- 
sponsibility and the consequent punishment. But his self-pre- 
servative act should not be employed as an argument or criterion 
to prove the sanity and responsibility of an individual. 
Again, the pathology of a criminal act may be so hidden and 
obscure as to defy the ordinary means of detection. In other 
words, the physical act of the crime may be but a bubbling ex- 
pression of its hidden pathological source, which lies deep in 
the substrata of a diseased intelligence. Instances of this variety 
often furnish the bone of medico-legal contention. 
The author established at the Indiana State Prison and the 
Indiana Hospital for Insane Criminals in 1911 a psychopathic 
laboratory for research in clinical criminology. Five thousand 
prisoners were examined physically, neurologically and psycho- 
logically in this laboratory with the special object in view to 
discover the types of crime that usually attend the different 
psychoses. Much has been written in a general way about the 
relationship of insanity to crime, but heretofore little has been 
published concerning the definite connection of disordered states 
of mind with the commission of criminal acts. Each psychosis 
in its relation to criminal behavior will be dealt with separately 
in this chapter. 
EPILEPSY 
History is replete with examples of the causal relationship that 
this disease has sustained to delinquency. The remotest ages of 
antiquity furnish us with very striking examples. Mythology RELATIONSHIP OF INSANITY TO CRIME 
315 
tells us that Hercules murdered his wife, Ophelia, and their chil- 
dren, during one of those unconscious automatic states that are 
characteristic of epilepsy. Seneca tells us: "One day, as Her- 
cules was offering a sacrifice to Jupiter, he suddenly stopped, 
rolling his bloodshot eyes in a hideous manner, the saliva ran 
down his beard, his smile was convulsive and strained, and lay- 
ing aside his garments, he became very much agitated. They 
thought he had returned to his senses, when he suddenly rushed 
to his weapons, ran after his father, his own children, and every- 
body, till finally he slew his wife and children. He was about 
slaying his father when Pallas appeared and checked him, throw- 
ing him on the ground. Then he quickly fell into a profound 
sleep. As he awoke the sight of all the slain around him terrified 
him and his despair became extreme when the news was broken 
to him that he alone was the author of all this slaugther." 
Epilepsy is probably responsible for more pathological of- 
fenses than any other form of positive mental disease. It is 
very common for prison physicians to observe that many prison- 
ers have distinct dizzy spells, and these are many times true 
forms of petit mal which may be overlooked by a careless men- 
tal examination. 
Marked changes in the morals and the emotions are most con- 
stant characteristics. The epileptics, as a rule, are most mer- 
curial and volatile in their temperaments. The nearest trifles 
are sufficient to stir them to serious outbreaks of temper and 
violence. They are radicals of the most extreme type, and espe- 
cially is this true in the sphere of religion and politics. 
Their manner of living and their modes of behavior are prac- 
tically regulated by their appetites. They love power and noto- 
riety, and they shrewdly use immoral and illegal methods to 
secure these. They are extreme sensualists and are prone to 
commit sexual crimes, as rape, incest and sodomy. 
Delusions of persecution are common characteristics of the 316 
MANUAL OF PSYCHIATRY 
epileptic mental degeneration and therefore it is very easy to 
see why dangerous assaults should be so common among epi- 
leptics with their hair-trigger temperaments, their lack of emo- 
tional control and their impetuosity. 
Clouston has well said that "Murder by an epileptic should 
be looked upon as being as much a symptom of his disease as is 
larceny by the general paretic." 
Delasiauve forcibly states: "It is certain that on passing an 
epileptic, we elbow one who might be an assassin, and that epi- 
lepsy, through the delusional ideas it originates, furnishes a con- 
siderable share of the crimes ascribed to mental alienation." 
The phenomenon of epileptic automatism has long been ob- 
served, but a concise explanation of this phase of the disease 
has not yet been offered. We know, however, that some epi- 
leptics complete certain definite acts in a seemingly perfectly 
conscious and coherent manner, but in reality consciousness is 
practically blotted out, and when the individual regains his 
mental status there is likely to be no memory of any of the acts 
that he may have committed during such periods, or if he does 
have any memory, it is usually but an indistinct hypnogogic 
idea that closely corresponds to the dream state. 
The automatic acts of the post-epileptic stage more frequently 
follow the petit mal paroxysm and it is rare for criminal acts to 
be committed following a severe form of the major paroxysm. 
It is usually the rule that the actions which are performed in a 
post-epileptic automatic state are always the same in character. 
The act performed usually portrays in some manner an habitual 
movement that is customary to be made in normal consciousness. 
In the consideration of epileptic criminal acts we must bear these 
facts in mind. If called upon to give expert testimony as to the 
responsibility for criminal acts that may have been performed by 
an epileptic in the post- or pre-epileptic automatic state, we must 
determine whether the overt act was habitual in any character RELATIONSHIP OF INSANITY TO CRIME 
317 
or whether the person was accustomed to performing similar ac- 
tions when "at himself." 
It would be in perfect harmony with the observations that 
have been made to find an epileptic butcher who had assaulted 
another individual with a knife, nor would it be strange to find 
a soldier in a post-epileptic state shooting someone. But should 
a butcher kill an individual by administration of poison, we 
should be exceedingly slow to regard such a crime as an expres- 
sion of epilepsy, since the handling of drugs is a procedure foreign 
to the act of cutting meat. 
The condition known as psychical epilepsy is one in which the 
paroxysm is replaced by a nervous storm which is not accom- 
panied by the usual signs of epilepsy. "Psychic epileptics may 
commit all manner of crimes-thefts, arson, rape, assaults and 
homicides. They are not infrequently pyromaniacs, entirely 
without reason or impelled by the flimsiest motives." 
"The medico-legal aspects of this type of epilepsy depend, so 
far as responsibility is concerned, upon our ability to determine 
the existence of the automatic state at the given moment. This 
may be difficult to do beyond reasonable doubt, though if we can 
prove the person is a sufferer from epilepsy at the time, or ever 
had it in any form, we can always create a reasonable belief that 
the patient may have acted while in a seizure, without any intent 
whatever, and under conditions that should free him from re- 
sponsibility. 
"The evidence of the presence of epilepsy * * * needs to be 
carefully studied in order to arrive at a just conclusion in medico- 
legal cases. If it can be proven beyond reasonable doubt that 
the individual has epilepsy, the question of responsibility is not 
difficult after that. We may not be able, it is true, to say posi- 
tively that he was under the influence of a seizure at the moment 
an overt act was committed, while, on the other hand, we are 
equally as unable to prove that a seizure was not present. MANUAL OF PSYCHIATRY 
318 
Psychic convulsions defy all ordinary methods of detection. 
They can readily be noted, however, by one trained in the ob- 
servance of their expression." 
PARANOIA AND PARANOID STATES 
Paranoia and allied paranoid states furnish us with a very 
large quota of pathological crimes. The most common of these 
are homicide, homicidal attempts, assault and battery, black- 
mail, perjury, impersonation of officers and sexual crimes. The 
most dangerous of all insane patients is the one who harbors in 
the recesses of his diseased mentality systematized delusions of 
persecution. This is especially true of the paranoiac, who many 
times appears to be intellectually normal and occasionally, aside 
from his paranoidal tendencies, he may be the superior of the 
average individual. The proper perspectives of life are impos- 
sible for the paranoiac since each instance and circumstance is 
colored and tinged by an abnormal sensibility and reaction to 
the most commonplace and trivial affairs. 
The paranoiac in the stage of persecution, out of the most 
insignificant circumstance, constructs a nebula of persecutory 
ideas which are intangible and obscure. Finally these hazy, 
indistinct ideas of persecution take on a more definite character, 
and then, step by step, supportive and contributive ideas are 
formed and elaborated which build up a definite, systematized, 
delusional preconception or system of thought through which 
must pass every idea that is translated into action. 
This delusional formation is so closely and intimately con- 
nected with the whole of consciousness, that it regulates and 
dominates the individual's manner of feeling, thinking and act- 
ing. It is easy to see, therefore, that any paranoiac is a poten- 
tial homicide while harboring delusions of persecution. Should 
he believe that his supposed enemies have designs upon his life, 
or that they desire to make him the butt of their ridicule, or the RELATIONSHIP OF INSANITY TO CRIME 
319 
object of some diabolical conspiracy, it is not at all strange that 
the persecuted should turn persecutor. 
He employs logical methods of argument to convince himself 
that he is perfectly right in seeking means to protect himself 
against machinations, and should he ever be called into court to 
explain some of his erratic behavior, he is more than convinced 
that he is justified in seeking any measure that he may see fit to 
employ. 
DEMENTIA 
The crimes of those suffering from dementia praecox partake 
of the fundamental basic characteristics of mental enfeeblement 
that mark this psychosis. The misdemeanors and unlawful 
offenses of those affected with this disease are characterized by 
more or less defect of reason and judgment, a marked emotional 
poverty, a more or less complete state of indifference, a condition 
of puerility and often a thoughtless, senseless and impulsive 
brutality. A very large number of violations of the law com- 
mitted by insane persons are directly chargeable to dementia 
praecox. "Many of these cases go to swell the ranks of the crim- 
inals, the prostitutes and hoboes, and are often mistaken for 
cases of feeblemindedness. Wilmans, in a study of one hundred 
and twenty-seven vagabonds, found sixty-six cases of dementia 
praecox." 
Cases of arrested dementia praecox are often noted in prison. 
In these types of this disease, the progress of the underlying 
dementia is inhibited, and though the psychosis fails to reach a 
stage of dementia, the individual never again reaches his own 
normal mental status. 
A distinct difference corresponding to the three main divisions 
of dementia praecox is shown in the character and the circum- 
stances attending the crimes committed by the patients with this 
disorder. The crimes and misdemeanors of hebephrenia partake 320 
MANUAL OF PSYCHIATRY 
of the character of this form of dementia praecox-the crimes 
are petit larceny, trespass, vagabondage, drunkenness, the break- 
ing of box cars, sexual offenses, and public prostitution in the 
female. The offenses which often go to make a part of the cata- 
tonic symptom-complex occur with much less frequency than in 
the paranoid and hebephrenic form. The crimes and misde- 
meanors of this type are marked by impulsiveness, a lack of 
premeditation, thoughtlessness, and usually no effort is made by 
the patient to escape the consequences entailed by criminal 
actions. The catatonic makes vicious assaults, commits murder, 
and destroys property by incendiarism. The paranoid form fur- 
nishes a large number of criminals; the delusions of persecution 
lead to assault, homicides, theft of property, blackmail and per- 
jury. The crimes of hebephrenia and paranoid dementia praecox 
are about equal in number. 
GENERAL PARESIS 
The crimes of general paresis as compared with epilepsy, de- 
mentia praecox and paranoid states are comparatively rare. Of 
two hundred and five admissions to the Indiana Hospital for the 
Insane Criminals but five patients were general paretics. 
The criminal offenses of general paresis generally fall into one 
of the following categories: immorality, alcoholic debauch, inde- 
cent behavior, thievery, dishonest speculation, forgery, and very 
rarely homicide and suicide. The misdemeanors of paresis gen- 
erally occur in the incipient stages of this disease. The moral 
qualities of the mind share in a very large way in the general 
degeneration. Very often the moral symptoms are the first to 
point to paresis. The paretic fails to understand and seems 
entirely oblivious to the moral relations that he sustains to 
society and his family. His speech, which was formerly chaste 
and decent, becomes filled with profanity and obscenity. The 
once temperate individual indulges in wild alcoholic debauches, RELATIONSHIP OF INSANITY TO CRIME 
321 
and the formerly respectable husband and father seeks the com- 
pany of the public prostitute openly and without shame. 
"Volition, as the highest function of the mind, is one of the 
first to suffer in general paresis. The loss of control, both of 
actions and of ideas, is one of the earliest symptoms, and in the 
fully developed stages there is no longer any volitional direction 
of the thoughts, and consciousness is filled with the creations of 
a morbid phantasy, and with such sensorial impressions as 
chance to rise. This failure of will power and of all persistency 
of purpose makes the general paretic a comparatively easy sub- 
ject for management." 
The paretic manner of committing misdemeanors, and the en- 
vironments and circumstances attending them, generally leave 
room for little doubt as to the source and nature of their real 
origin. The patient has no apparent knowledge of the quality 
and nature of his overt act. The paretic seldom tries to hide his 
crime and he displays no foresight or caution. If on a tour in a 
department store, the rich and well-to-do patient may steal ar- 
ticles of small value, such as handkerchiefs and gloves. He will 
pocket them under the eyes of the clerk in a state of apparent 
forgetfulness, after having examined them as a prospective buyer. 
Magnan recites the case of a paretic who asked the aid of a 
policeman to help him steal a barrel of wine. The perfect frank- 
ness, innocence and apparent reasonableness of the request made 
upon the policeman so impressed him that he assisted the paretic 
to carry out his theft. 
"The apparent kleptomaniacal propensities of the general 
paretic consist mostly in an automatic appropriation of whatever 
articles attract his attention rather than in any perverse desire 
to steal. In the demented stage he still continues to accumulate 
things when he is no longer capable of making any distinction 
as to ownership." 
Under the dominating influence of grandiose delusions, the vic- 322 
MANUAL OF PSYCHIATRY 
tim of paresis forges checks, makes fraudulent claims on prop- 
erty, gives false promissory notes, makes wild speculations in the 
market and undertakes impossible financial operations, without 
apparent knowledge of the quality of his acts. 
MANIC-DEPRESSIVE INSANITY 
Crimes of the manic-depressive psychoses are relatively rare. 
The alternate cycles of good behavior and freedom, crime and 
imprisonment which the author has noticed in habitual crim- 
inals somewhat resemble the manic-depressive psychosis with its 
intervals of lucidity, separated by periods of depression and ex- 
citement. In the period of remission of the cyclic form of crim- 
inality the prisoner is exceedingly well behaved and often takes 
a very active part in the religious services and societies at the 
prison, and often it is thought the individual has reformed and 
that he will become a model citizen. He is sooner or later dis- 
charged from the prison and he does exceedingly well for a lim- 
ited time. But shortly our hopes are dashed to the ground, for 
a second cycle of criminality develops, new crimes are commit- 
ted, and the individual is returned to the prison from which he 
was but recently discharged or is sent to some institution in 
another state. 
Depressive Phase.-The most common violent act of this 
phase is suicide. All melancholic patients are potential suicides, 
and in a state of raptus this act is frequently performed in public 
and without premeditation. The depressive patient sometimes 
becomes so occupied with a single idea that it amounts to an 
obsession. These ideas are often very terrifying and brutal, and 
because they occupy the entire field of consciousness there often 
develops a state of "raptus melancholicus" in which their absorb- 
ing obsessions are translated into murder, vicious assaults, muti- 
lations of the body, especially of the genitals, and the most pain- 
ful forms of suicide. RELATIONSHIP OF INSANITY TO CRIME 
323 
Consciousness is markedly clouded in these outbreaks by de- 
lirious passion, and the memory, if retained at all, is imperfect 
and hazy concerning any actions performed during this period. 
In the state of raptus, guided by a delusional sympathy, a 
mother will murder her children to protect them from hardship, 
trials and supposed evils with which she thinks they are threat- 
ened. An individual once made an attack on an English king 
knowing that such a crime would result in his death. He was 
impressed with ideas of his own sinfulness and unworthiness and 
thought that his own death was necessary for the good of human- 
ity, but because he was so scrupulous about the sin of suicide 
he assaulted the king, knowing that the punishment for this act 
was death. 
Manic Phase.-The crimes of the manic phase are also rare. 
The extreme psychomotor activity intereferes with the accom- 
plishment of definite criminal acts. The patient is destructive 
rather than criminal. He is given to the demolition of furniture, 
mirrors and window panes. They not infrequently disturb public 
peace by running amuck through public thoroughfares. They 
often frequent saloons and indulge heavily in liquor, thereby 
becoming obstreperous and unruly in public places. The ordin- 
ary womanly modesty is frequently lost in the manic phase. 
Female patients of this type are often arrested and charged with 
public indecency and exposure. Nymphomania, kleptomania 
and dipsomania are not uncommon symptoms. The maniacal 
excitement occasionally assumes a character of extreme fury and 
frenzy, during which vicious assaults and homicides are commit- 
ted. 
HYSTERICAL INSANITY 
It is not at all to be wondered at that crimes, misdemeanors 
and the violations of morality should be found in the symptom- 
complex of hysterical insanity. The exaggerated impression- 324 
MANUAL OF PSYCHIATRY 
ability to external stimuli, the abnormal tendency to simula- 
tion, the excessive emotionalism, the volitional impairment, ren- 
der the patient a plaything of his whims and passion and the 
easy victim of evil circumstances. The combination of these 
named psychic attributes of this mental anomaly create or con- 
stitute a condition of moral incoordination. 
Delusions of persecution are to be expected in the hysteric 
whose abnormal sensitivity to the slightest irritating trifles trans- 
lates the most common relations of life into schemes and ma- 
chinations for his injury. It naturally follows that homicidal 
assaults should grow out of this disordered, paranoid state of 
mind. 
The basic eroticism of hysteria leads to sexual crimes. The 
hysterical ascetic in his life of imperfectly repressed sexual de- 
sires and celibacy often sinks to a state of homosexuality, which 
finds relief in such sexual crimes as sodomy and bestiality. Other 
hysterics, through fear of venereal disease, through dread or 
shame, or a horror of being detected in illicit sexual relations, 
frequently commit rape on infant children. 
Individuals of this type are to be found in every prison. 
Often overt acts are perpetrated in the periodic episodes of this 
psychoneurosis that are attended by states of amnesia. 
"Many of the cases of blackmail and false accusations against 
physicians may be credited to this form of hysteric derange- 
ment in females, and we have known one or two striking in- 
stances of the kind. One, a young woman, well connected, but 
cut loose from her family and rather repudiated by her relatives, 
used to frequent doctors' offices and have hysterical attacks 
there, and in one or two cases, at least, attempted to get up 
compromising situations, and once succeeded so far as to give 
considerable mental uneasiness for a time to a rather prominent 
physician. There are cases on record where still more serious 
consequences have resulted; men have been convicted of crimes RELATIONSHIP OF INSANITY TO CRIME 
325 
of which they were innocent, on false testimony of hysteric 
women." 
"While this mental disorder is by far most frequent in the fe- 
male sex, it is not unknown to males; of course, in these cases 
the symptoms are somewhat modified, but it occurs only in men 
with somewhat abnormal and feminine mental organizations. 
In some of these, sexual perversion is a notable symptom, and 
it seems probable that this hysteria is at the bottom of many 
cases of this abnormality." 
"In male hysteric insanity we see many of the same tendencies 
to morbid emotionalism, eroticism, false accusations, the exag- 
gerated suggestibility, certain kinds of delusive conceptions, oc- 
casional threats or apparent attempts at self-injury or suicide, 
refusal of food, etc., that we observe in the female, but actual 
hysteric convulsive attacks are very rare, and the well-marked 
hysteric physical stigmata are also uncommon. Male hysteric 
insane are more likely to be suicidal or homicidal than are the 
females." 
"Something may be said in regard to traumatic hysteria, which 
sometimes amounts to a kind of insanity, showing itself in an 
exaggerated valuation of physical disabilities and a certain moral 
weakening that leads the individual to overact and sometimes 
to simulate. There are probably sometimes actual hallucinations 
and certain delusive conceptions. These cases may be regarded 
as rare, though hysteria from this cause is common. They have 
chiefly a forensic importance." 
The hysterical type of prisoner is the bete noir of the prison 
surgeon. He is irritable, quarrelsome, goes about seeking to 
provoke an argument, and constantly complains that he is ill- 
treated by the prison officials, that unfair tasks are assigned to 
him, and that fellow prisoners steal his tools and delay his 
work. He constantly makes demands for interviews with the 
disciplinary officer. He is rebellious at discipline; finds obedi- 326 
MANUAL OF PSYCHIATRY 
ence to the prison's simplest rules a hard task. At other times 
he is extremely cheerful, vivacious, and his actions are liable to 
overstep the bounds of prison convention. This brief period of 
apparent improvement in conduct is usually followed by a train 
of hypochondriacal complaints. 
This type of prisoner comes to the sick line every morning. 
One day he complains of precordial distress, the following day he 
confidentially tells the prison physician that he has very fre- 
quent nocturnal emissions, that he is troubled with nightmare 
and insomnia. At the next morning's sick call he gives a new 
revelation concerning gastric disturbances with which he suffers. 
In a few days he becomes extremely depressed and melancholy. 
He imagines himself the victim of conspiracy by the officials of 
the institution. He becomes lachrymose and he relates his griev- 
ances to his fellow prisoners to create sympathy. Failing to do 
this he frequently pretends to attempt suicide. Should this fail 
to arouse the sympathy which he morbidly craves, he frequently 
becomes maniacal, throws his food on the floor, breaks the dishes, 
tears his clothing and talks in an incoherent and senseless man- 
ner. After a few days, whether placed in the hospital or not, 
his mental condition returns to its normal state and in course 
of time another cycle of such conduct is enacted. 
The hysterical criminals constitute possibly four per cent of 
the insane cases in prisons among the male prisoners, and this 
percentage is much higher among the female delinquents. Dr. 
Spaulding of the Woman's Reformatory in Massachusetts, stated, 
in a recent report, that eleven per cent of the female offenders 
showed manifestations of hysteria. It has been noted among 
female prisoners that maniacal hysterical outbreaks occur very 
frequently and more especially at the time of the menstrual 
periods. The following stenogram is taken from Mrs. Mary 
Carpenter's "Female Life in Prison": " 'Miss G., I'm going to 
break out tonight.' 'Oh, nonsense; you won't think of any such RELATIONSHIP OF INSANITY TO CRIME 
327 
folly, I'm sure.' 'I'm sure I will.' 'What for?' 'Well, I've made 
up my mind, that's what for. I shall break out tonight. See if 
I don't.' 'Has anyone offended you or said anything?' 'N-No, 
but I must break out.' 'And then you will go to the 
dark cell.' 'I want to go to the dark.' " And the breaking out 
often occurs as promised; the glass shatters out of window frames, 
strips of sheet and blankets are passed through or left in a heap 
in the cell, the guards are sent for, and there is a scuffling and 
fighting and scratching and screaming that pandemonium might 
equal, nothing else. 
PUERPERAL INSANITY 
Puerperal insanity is a generic term applied to certain psy- 
chotic symptoms which occasionally attend the physiological 
epochs of pregnancy, parturition and lactation in those who 
possess a hereditary predisposition. The causal factors operating 
to produce this psychosis are the lack of proper medical atten- 
tion at the time of childbirth, the infection and exhaustion, 
shock and hemorrhage, the mental anxiety and fear attending 
this physiological cataclysm. It has been claimed that this 
mental disturbance takes place about twice as often in illegi- 
timate pregnancies as in legitimate ones. This fact seems to in- 
dictate that the psychogenic factor of worry, remorse and shame 
exert a tremendous influence for the production of this disorder. 
Occasionally violent states of mania and frenzy are noted in 
puerperal insanity and during these periods of great motor ex- 
citement, restlessness and delirium, criminal acts are committed, 
and chief among them are infanticide, suicide and homicide. 
A large percentage of infanticides may be charged to the in- 
sanity attending the puerperium. It is a strange perversion of 
the maternal instinct for a mother to murder her helpless off- 
spring, and in every case of puerperal insanity the infant should 
be taken from its mother. It seems as though this mental dis- 328 
MANUAL OF PSYCHIATRY 
order is not confined to human beings alone. It is a well-known 
fact that horses, cows, rabbits, squirrels and cats often kill their 
young at birth or soon after. It is a very frequent occurrence 
for a female hog to kill and devour her entire litter. 
"When the disease develops at this time, delirium is common, 
particularly in cases occurring early-before the fourteenth day. 
Here also there are, in at least half the cases closely observed, 
prodromal symptoms during pregnancy. These symptoms may 
have been overlooked, or the offset may arise with startling sud- 
denness accompanied by suicidal or homicidal tendencies. Fever, 
which is commonly present, may be very high in septic cases. 
If the patient is maniacal, which is the most common type, she 
is sleepless and violent and attempts to destroy those about her. 
There are delusions and hallucinations. The ideas and lan- 
guage of the patient flash from her with remarkable rapidity 
and incessant change. Now sensuous, obscene, profane, and 
making attempts at self-exposure; in an instant she may revert 
to religious ideas, to indulge in prayer and the singing of hymns. 
In one case, that of an illegitimately pregnant colored girl of 
nineteen, the writer was thought to be the Almighty, from whom 
the girl piteously besought pardon for her sins. The moment 
while counting her pulse he was turned upon with a frenzy from 
which he barely escaped, the patient, now terrorized by his pres- 
ence, believing him to be Satan himself, upon whom she spat 
with fury. Within a very short time he left her singing a Sun- 
day school song, which was soon followed by word pictures of 
obscene situations mingled with revolting profanity. Melan- 
cholia in the puerperium occurs less frequently than mania- 
usually after the fourteenth day-and it is very apt to be ac- 
companied by persistent attempts at suicide, requiring unremit- 
ting watchfulness on the part of the attendants; delusions in- 
volving frequently the husband's fidelity, and hallucinations of 
sight and hearing are commonly present." RELATIONSHIP OF INSANITY TO CRIME 
329 
SENILE PSYCHOSES 
It is commonly observed that, as the period of senescence ap- 
proaches, the fires of passion are cooled, the ambitions of youth 
are quieted, the scheming and planning of youthfulness for the 
future successes and work to be accomplished ceases, and all is 
changed into a life of reminiscences, metaphysical and religious 
speculation. We pay the proverbial reverence to gray hair, the 
stooped form, the slow, unsteady, tottering gait, and to the 
kindly, human sympathy so characteristic of the aged. 
But this senile period of mental and physical decay is not al- 
ways attended by a peaceful and undisturbed serenity. Occa- 
sionally there is a profound moral deterioration. An even, quiet 
spirit gives way to excessive irritability. The senile dement 
objects to any change in this manner of living. He becomes ex- 
ceedingly egotistical and unreasonable. He makes senseless de- 
mands upon his wife and children, and it is not an uncommon 
occurrence for vicious assaults to be made on them, should they 
neglect his slightest whim. 
The formerly chaste and respected individual becomes in- 
temperate, his conversation is filled with coarse and obscene re- 
marks. Satyriasis is not an uncommon symptom, and this mani- 
fests itself in acts of rape, especially on young female children, 
or by disgraceful or bigamous marriages and indecent exposure 
of person. 
I have observed in a hundred and seventy-five cases of rape 
and attempts at rape that I have studied, that two-thirds of 
these sexual crimes were committed by decrepit and physically 
defective individuals, in whom the physical and mental signs 
of senile decay were evident. 
In some instances in senile insanity, there develops a paranoid 
state with delusions which may be loosely organized, system- 
atized, and accompanied by auditory hallucinations. Conscious- 330 
MANUAL OF PSYCHIATRY 
ness is fairly clear and orientation is but little disturbed. The 
emotions are exceedingly unstable, and tears and laughter can be 
alternately produced in a space of a few seconds. Homicides 
are frequently a symptom of this form of senile insanity. 
Regis, in speaking of misdemeanors and crimes of senile in- 
sanity, says: ''Their actions all carry the stamp of dementia. 
They are: absurd and infantile thefts, like those of general par- 
alytics, but even more foolish; sudden and causeless fits of pas- 
sion; ridiculous and heedless attempts at suicide; there are also 
especially libidinous actions, obscene' exhibitions of themselves 
in public, attempts at rape, unnatural crimes, all resulting from 
lack of conscience and absolute loss of the feeling of modesty." 
Arteriosclerotic Dementia.-The unlawful acts of this psy- 
chosis are essentially the same in character as those of senile 
dementia, with the possible exception that homicide and homi- 
cidal attempts are slightly more frequent because of the para- 
noid nature of the delusions and hallucinations entertained by 
this class of patients. Their crimes usually show a little more 
premeditation, lucidity, provision and foresight to escape the 
consequences of illegal acts. 
CEREBRAL SYPHILIS 
Psychopathic states are likely to develop during any stage of 
syphilis, but they more commonly occur during the secondary 
and tertiary periods. They appear in the form of a delirious 
mania or acute depression. There is a profound disturbance of 
the moral and emotional qualities. The maniacal excitement 
may consist of any degree of psychomotor activity ranging from 
simple cerebral excitement to a state of mania attended by au- 
tomatic agitation, incoherence and violence. After this state 
of mental alienation there may follow a mental lethargy and 
sluggishness, a clouding of consciousness, a defective ideation 
and a perversion of the sentiments. In the depressed form of RELATIONSHIP OF INSANITY TO CRIME 
331 
acute syphilitic insanity the patient is often exceedingly morose 
and sullen. He may entertain delusions of persecution, he may 
be fearful of poisoning or of secret enemies. The delusions are 
usually attended by olfactory, gustatory and aural hallucina- 
tions. 
'Tn some cases the psychical defect may show itelf in the field 
of the moral sentiments by indifference, brutal conduct, selfish- 
ness and a tendency to revelry." 
"Among the early symptoms are irritability, culminating in 
alarming explosions of anger or in acts of violence. Suspicion, 
too, is heightened and takes the form of delusions of persecution. 
These delusions often arise from the many strange and annoy- 
ing sensations to which the patient is subject and which he seeks 
to explain by reference to external agencies. Thus the paraes- 
thesiae are attributed to electricity or irritating gases, which en- 
emies use as means of torment. The hallucinations of taste and 
smell, which may be due to local syphilitic processes, lead to 
delusions of poisoning or of foul odors, which patients believe 
are generated in their rooms at night to injure their health." 
"Hallucinations of sight and hearing are also common, and 
they are often the result of specific lesions of the organs of 
sense. Their general character, furthermore, is disagreeable, 
like the prevailing emotional tone, and they sometimes rein- 
force and at other times are the sole origin of the delusions of 
persecutions." 
"The diagnosis of syphilitic insanity must rest not only on 
the history of specific infection, but also on the actual presence 
of syphilitic lesions, which may reasonably be supposed to bear 
a causative relation to the mental disease. If the physician is 
called to pronounce an opinion in a case with something like the 
following medley of symptoms, he need not hesitate to diagnose 
syphilitic insanity. These symptoms are not all supposed to 
be present in a single case, and a few of them would suffice for 332 
MANUAL OF PSYCHIATRY 
a diagnosis, and they are chiefly as follows: Great irritability 
and violent outbreaks of temper, confusion of ideas and loss 
of memory, exacerbations of mania or of hypochondriacal me- 
lancholia, and a constantly progressive dementia, accompanied 
by cephalalgia, insomnia, vertigo, syncope, apoplectiform at- 
tacks, sudden and temporary paralysis of cranial nerves, loss 
of power in single muscles or in one arm or less, loss of sight and 
optic neuritis, or loss of hearing, and a sudden and unaccount- 
able remissions in all the symptoms." 
DRUG PSYCHOSES 
Under this title of drug psychoses will be considered the aber- 
rant and disordered mental states due to the use of alcohol, 
cocaine and morphine. 
Alcoholic Insanity.-Alcoholic insanity is a generic term 
employed to embrace the various forms and types of reaction 
which follow alcoholic indulgence. We have more or less ar- 
bitrarily applied to these different alcoholic reactions the terms 
acute and chronic drunkenness, delirium tremens, alcoholic hal- 
lucinosis, dipsomania, alcoholic pseudo-paranoia, alcoholic 
pseudo-paresis, alcoholic epilepsy and Korsakow's psychosis. 
The disastrous effects of the narcotic, alcohol, on the brain 
and central nervous system are to be seen every day throughout 
the civilized world. Acute alcoholic intoxication or the ordinary 
form of drunkenness, from a psychological viewpoint, is but 
a transitory form of insanity. "Both psychologists and jurists 
have properly, however, maintained a distinction between those 
mental disturbances produced by the direct imbibition of alco- 
holic liquids, and which cease in a few hours after the imbibition 
ceases, and those mental derangements and hallucinations that 
may continue for days, weeks or months after all use of alcohol 
has ceased." 
The exact relationship that alcohol bears to crime is problem- RELATIONSHIP OF INSANITY TO CRIME 
333 
atical and cannot with mathematical precision be determined. 
I found that ninety-three per cent, of three thousand prisoners 
were users of some form of alcoholic beverages and that eighty- 
three per cent, claimed that they used this narcotic to excess, 
getting drunk at very frequent intervals. 
Prison authorities, and especially prison surgeons, know that 
many prisoners in order to have an excuse for their overt acts, 
readily attribute their crimes to temporary states of drunkenness. 
Therefore statistics on alcoholism from penal institutions and 
reformers are to be taken cum grano salis, for they are more or 
less inaccurate. 
Apropos of this subject, Mercier has stated: "The insanity 
that is most frequently associated with crime and directly leads 
to crime in a large number of cases, is undoubtedly the insanity 
of drunkenness. In nine years, one and three-quarters of a mil- 
lion of persons were sentenced, in courts of summary jurisdiction 
in this country (England), for offenses committed during drunk- 
enness, and to which the drunkenness contributed, even if it 
were not, in every case, the efficient cause, without which the 
offense would not have been committed." 
The usual answer that I received from prisoners during my 
examination of them concerning the cause of their crimes was 
generally one of this sort: "I was drunk; I did not know what 
I was doing; I may or may not be guilty; I cannot remember." 
These excuses for crime are so common and so easily made, 
that the courts are extremely reluctant to place any confidence 
or value in them. In many instances, however, they are ab- 
solutely correct concerning the state of consciousness and mem- 
ory. 
We find in the misty, nebulous mental states that occupy the 
borderline regions which separate insanity from sanity, con- 
ditions of automatism, somnambulism, double consciousness, 334 
MANUAL OF PSYCHIATRY 
cataleptic states, conditions of frenzy and furore, all of which 
are attended by amnesia. 
During these apparent dream states, which are probably due 
to disassociation or cleavage of consciousness, every conceivable 
crime in the criminal category has been committed. 
In delirium tremens, murders have been committed by the 
frenzied alcoholic under the delusion that those about him are 
his enemies. Suicide is not an infrequent termination of this 
form of alcoholism. The dilapidated, deteriorated mental state 
of chronic alcoholism is conducive to crime, for the moral sense 
is perverted, the will power is practically inert and the individual 
becomes the abject slave of his own passions. 
The crimes of acute alcoholism are petty thefts, larceny, for- 
gery, rape, incest, sodomy, assaults and homicides. Petty thefts, 
obscene exhibitions and sexual crimes have been noted in alco- 
holic pseudo-paresis. 
Alcoholic hallucinosis, which is attended by persecutory de- 
lusions of a sexual nature and by hallucinations, especially of 
the auditory variety, leads to homicide and homicidal attempts. 
I have observed that a large number of wife murderers com- 
mitted their crimes when reacting to delusions of marital in- 
fidelity. 
The same crime producing delusions and auditory hallucina- 
tions are characteristic of alcoholic pseudo-paranoia. We 
usually find dipsomania to be dependent upon neuropathic hered- 
ity, diseased conditions brought about by trauma, malnutrition 
and lack of proper food. The inebriate is, in fact, a diseased 
person. 
"The best statistics show that from seventy to eighty per cent 
of persons who drink spirits convulsively, and are called inebri- 
ates, have a defective heredity. All studies of the steady drinker 
show a profound and progressive impairment of all the senses, 
functional activities of the body and reasoning. The more accur- RELATIONSHIP OF INSANITY TO CRIME 
335 
ate the measurements are made, the more positive the deviation 
from the normal becomes." 
"There can be but little doubt that much the larger number of 
those shocking homicides which disgrace the criminal annals of 
civilized countries, in which mothers, or children, or both, have 
been suddenly slaughtered in the midst of the father's debauch- 
ery, have been the direct result of true paroxysms of mania a 
potu, such as we have briefly described. The medico-legal bear- 
ing of this class of cases deserves more thorough investigation 
than it has hitherto received. And as one attack of this form of 
mania leaves the patient more disposed to another, whenever 
indulging in the use of alcoholic drink, they constitute the most 
dangerous class of inebriates." 
It will be well to review briefly the attitude and beliefs that 
society has entertained concerning alcoholism and responsibility. 
Lord Coke of England set forth the idea in his ruling in the 
seventeenth century that drunkenness and inebriety augmented 
a crime or misdemeanor and therefore called for an increase of 
punishment. 
For many years moralistic speculation and theories have deter- 
mined in a large degree the attitude society has held toward 
drunkenness. 
The reformers and philanthropists have ever held the inebriate 
morally responsible. They have endeavored fruitlessly to re- 
habilitate the dipsomaniac by moral suasions, recriminations, 
insults and punishments. 
It cannot be denied that moral treatments do exercise some 
influence in cases of inebriety, but they should always be sec- 
ondary to medical and hygienic measures. 
Dr. Crothers, America's leading authority on alcoholism, con- 
vincingly stated, relative to this phase of the subject, the follow- 
ing: "It is a delusion to interpret acts associated with premedi- 
tation and reasoning in inebriates as evidences of sanity. It is 336 
MANUAL OF PSYCHIATRY 
a delusion to consider inebriety and alcoholism as not impairing 
the sanity and integrity of the brain and body. It is a delusion 
to consider such persons as possessing free will and judgment, 
with consciousness of their condition and ability of control. It 
is a delusion often repeated and has become incorporated in 
jurisprudence, that alcohol may be used to give capacity to com- 
mit crime. In reality this is true, but in a very narrow limit." 
"The exciting stage following the use of alcohol might be 
limited to ten minutes or an hour, but after that, there is no cer- 
tainty that any act premeditated could be carried out. The fact 
is sustained by unmistakable evidence that all crimes committed 
by such persons are the acts of defective minds. All this signifies 
a recognition of the condition of the criminal, not to diminish the 
punishment, but to change it to more rational lines. Criminals 
of this class need control, care and changed conditions. They are 
clearly defectives and degenerates who have lost the power of 
rational thought and conduct." 
The positions taken by our courts on the subject of intoxica- 
tion are contradictory and illogical. If an individual in a state 
of intoxication makes a will, signs a contract, a deed, a promis- 
sory note, or a bank check, the courts of law do not hold such 
papers and testaments as valid or legal, if a proof of intoxication 
can be brought to bear. Law in this case questions and even 
denies the responsibility and the capacity of an intoxicated indi- 
vidual to execute a legal instrument. 
In the practice of criminal law this is quite the reverse. If a 
drunken man commits a crime while intoxicated he is held to be 
responsible and qualified to commit a crime. Yet psychologically 
and physiologically, the mental impairment, the lack of reason 
and judgment, the incapacity to act normally are just the same 
whether an offense be committed against criminal or civil law. 
Our conceptions concerning alcoholism and responsibility must 
change. Society in general and law in particular still look upon RELATIONSHIP OF INSANITY TO CRIME 
337 
an individual as the possessor of an absolutely free will. Can we 
look upon intemperance as prima facie evidence of deliberate 
viciousness? This is hardly possible in the light of recent 
research. 
It has been demonstrated beyond the shadow of a doubt that 
the dipsomaniac is always a neurotic. His nervous system is 
impaired by heredity, disease or trauma. The defects of his 
brain and central nervous system produce at intervals an in- 
satiable, uncontrollable craving for alcoholic stimulants. 
Morphinic Insanity.-The medico-legal aspects of the nar- 
cotic drug habits need to be more carefully studied than they 
have been in the past. Eight per cent of the prisoners received 
at the Indiana State Prison were users of cocaine, morphine or 
other narcotic drugs. Fully five per cent of all the crimes for 
which prisoners were committed to this institution were due 
directly or indirectly to the use of these agents. 
The victim of morphinic insanity is absolutely a slave to the 
almost insatiable desire that possesses him to use opium or any 
of its alkaloids. The moral degradation and misery of oxymor- 
phinism will lead the habitue into the performance of any crime 
in his efforts to secure morphia. The drug victims will commit 
larceny, burglary, forgery, arson, blackmail, homicidal attempts, 
murder and sexual crimes to satisfy their morbid cravings. 
Women have many times been known to prostitute themselves 
to secure the drug. A very large percentage of the commercial 
prostitutes are morphino-maniacs. The psychotic disturbances 
of morphinism frequently develop a depressive and melancholy 
character, and these are attended by delusions of persecution and 
a tendency to suicide. Occasionally states of incoherence, con- 
fusion and mania are observed, during which periods homicidal 
attempts are frequently made. 
Police surgeon Dr. Guimball, who has had a wide experience 
with criminal drug habitues, says the following: "First, morphine 338 
MANUAL OF PSYCHIATRY 
causes defects of attention, particularly of sense observation; 
second, the ethical sense * * * is blurred. The victim is unable 
to discriminate any moral basis that should dominate. He acts 
from impulse; third, his will is lost and power of control over the 
impulses lessened. Both physical and mental impulses dominate 
him from the slightest exciting causes; fourth, the morphinist is 
literally a lunatic, only more subtle and concealed; like the dip- 
somaniac he is liable to be dominated any moment by impulses 
that are unforeseen; fifth, the responsibility, like judgment, is 
impaired and enfeebled. He is constantly doing acts and saying 
things the import of which he does not understand." 
Cocainism.-The criminal manifestations of cocaine insanity 
are essentially those of morphinism, except possibly that they 
are slightly more profound. The cocainists as a rule are very 
easily irritated, and their conduct is largely governed by violent 
impulses. Pronounced changes in their characters take place; 
the patients become dishonest and deceitful and seem to possess 
a morbid propensity for lying. The will power is markedly en- 
feebled; all sense of moral or legal responsibility is weakened; 
reason and judgment are greatly impaired. 
The development of a paranoid state is a very common occur- 
ence. The victim develops and entertains delusions of a perse- 
cutory nature; he becomes suspicious of his wife's attitude to- 
ward other men. Frequent homicidal assaults grow out of these 
delusions of marital infidelity. Erlenmeyer has observed that 
the sudden withdrawal of the drug from the cocaine fiend often 
induces a profound state of depression and delirium which is 
accompanied by persecutory delusions that render the individual 
an extremely dangerous person. Suicide is not an infrequent 
termination of chronic cocaine intoxication. 
The psychotic states dependent upon the chronic use of such 
narcotic drugs as cannabis indica, sulphonal, veronal, hyoscya- 
mus, chloral, bromides, ether, chloroform, belladonna, lead, ar- RELATIONSHIP OF INSANITY TO CRIME 
339 
senic and mercury, are usually acute or chronic confused para- 
noid conditions attended by delirium. 
FEEBLEMINDEDNESS 
The greatest causative mental factor of crime is feebleminded- 
ness. Several divisions of mental defect have been made, and 
while they are more or less arbitrary, they are very useful for 
the purposes of description. As we are only concerned with the 
symptoms of feeblemindedness that relate to crime, no other 
symptomatology will be described. 
Brutality and cruelty seem to be universal symptoms of imbe- 
cility. The precocious cruelty of the feebleminded which enables 
them to torture animals, to cripple birds, to tear the wings and 
legs off insects, to laugh at the pain of others, to inflict torture 
with delight, forms the basis, when they are physically able, 
for assault and battery and for homicidal attempts and murder. 
The easy disintegration or cleavage of consciousness which 
occurs so often in the feebleminded permits violent explosions of 
anger against those who interfere with their pleasure. Their 
wrath is shown by outbursts of fury and frenzied attacks; again 
it is exhibited by well calculated and cunning cruelty. 
The feebleminded, lacking in reason and judgment and devoid 
of all moral critique, commit all manner of sexual crimes without 
any feeling of restraint or shame. They masturbate openly and 
excessively. The imbecile father impregnates his own daughter, 
or he may commit sodomy with his own son. Imbeciles may 
attempt intercourse with their mothers and 11 sexual satisfaction 
with animals is frequently attempted. The great majority of 
cases of injury (sexual) to animals must be attributed to imbe- 
ciles." Many of the attempts to murder, and murder itself, 
committed by the mentally defective, are perpetrated when the 
person attacked resisted their erotic assaults. 
Often they are cunning thieves; articles of small worth seem 340 
MANUAL OF PSYCHIATRY 
to have a great attraction for them. To satisfy their vanity, 
they often steal wearing apparel. They set fire to property to 
appease their desire for the excitement which attends conflagra- 
tions. Many of the pyromaniacs who are a constant source of 
worry to the fire insurance companies are feebleminded persons. 
"Higher imbeciles are predisposed to systematized delusions, 
and more particularly to communicated insanity. Imbeciles 
are the near neighbors of paranoiacs and are apt to pay tribute 
to them by blindly professing their delusions on the occurrence 
of the slightest opportunity." 
"When a paranoiac is a propagandist of mystical ideas, and 
reigns as a sovereign or high priest, it is the imbeciles who com- 
pose his court and form the majority of his subjects. (Jacoby.) 
The contagion is favored by the affinity of tendencies in para- 
noiacs and imbeciles; every paranoiac is mildly imbecile, and 
every imbecile is at least a candidate for endemic paranoia if 
he lives in isolated and fanatical surroundings. * * * In epi- 
demics of religious and political delusions, it is among imbeciles 
that spies and traitors are most easily found. Their want of crit- 
ical power, their fickleness of character, and the servility that 
drives them to become the apostles and slaves of paranoiacs, 
whose ideas they do not understand, lead them also to surrender 
when intimidated by warnings, flattery and threats. Their intel- 
ligence is equally incapable either of originating a delusion or of 
spontaneously correcting a delusion; but it is accessible to the 
positive and negative suggestions of others, and does not appre- 
ciate how compromising it is to suddenly abandon a principle." 
"In the moral point of view the lacunae are perhaps more 
marked than in the domain of the intellect, and if these patients 
are capable of showing to varying extent sentiments and affec- 
tions of a low order, they are only the least elevated ones, and 
the lower instincts that dominate them. The majority are vain, 
gluttonous, cowardly, credulous, idle, irascible, inclined to vene- RELATIONSHIP OF INSANITY TO CRIME 
341 
real and alcoholic excesses and to acts of violence (Marce); 
nearly all are given to onanism, and some to unnatural crimes. 
At certain times they may be seized more or less suddenly with 
melancholic or maniacal attacks, during which they are particu- 
larly liable to commit acts of obscenity, or even arson, robbery, 
suicide, or homicide. When these attacks, which very often 
assume in them a periodical or circular character, occur many 
times, the patients soon fall into a condition of dementia." 
Alcohol plays a very important role as an element for the 
production of crime in the feebleminded. It serves to intensify 
the defect already existing; it weakens the already enfeebled 
volitional powers; it is influential in firing misguided, wild and 
erratic emotions. It distorts previously inefficient and irrational 
judgments. In fact, it raises to the nth power all potential and 
latent elements for criminality that lie in the constitution of 
the feebleminded. 
Feebleminded Prisoners.-I classed 23 per cent of the crimi- 
nals whom I studied as feebleminded. In the employment of 
this term I have endeavored to limit its application to those 
persons who as a group possess "All degrees of mental defect 
due to arrested or imperfect mental development as a result of 
which the person so affected is incapable of competing on equal 
terms with his normal fellows, or of managing himself or his 
affairs with ordinary prudence." This, in the language of the 
American Association for the Study of the Feebleminded, is 
necessary for the diagnosis of feeblemindedness. 
Various estimates have been made by different psychologists 
and physicians as to the number of feebleminded persons in 
penal and reformatory institutions. This number has varied 
from 20 to 60 per cent, and these differences can be easily under- 
stood when we consider the various natures of the institutions 
giving these data and the general broadness or narrowness or the 
psychopathological examination employed in such determinations. 342 
manual of psychiatry 
Dr. Walter Fernaid has stated: "At least 25 per cent of the 
inmates of our penal institutions are mentally defective and 
belong either to the feebleminded or to the defective delinquent 
class." 
"At any rate we should have twenty thousand such individ- 
uals in adult prisons, and six thousand in juvenile reformatories, 
making a total of twenty-six thousand defective delinquents 
in actual custody, not to mention those who have never been 
arrested and the large number who have been discharged or 
paroled from institutions and are now at large. There are doubt- 
less as many defective delinquents at large as there are in 
Custody." 
Since it has been shown that the insane may commit dangerous 
and criminal acts, we are confronted with the problem of seg- 
regating and caring for this type of anti-social persons. The 
class of insane offenders may be divided into two groups; namely, 
the insane criminal and the criminal insane. 
There is need for an explanation of these terms; the last term 
especially needs some elucidation to explain what seems to be 
an apparent contradiction. How can an individual be both 
insane and criminal at the same time? The classical school of 
? • 
criminologists has denied this possibility on the theoretical 
grounds that no crime can be committed without criminal intent, 
and that the insane do not have criminal intent of mind because 
of their insanity. From a standpoint of rhetoric this argument 
is logical enough. Admitting for argument's sake the plea of 
the classical school of criminology, that it is impossible for an 
individual to be both criminal and insane at the same time, we 
are confronted with the imperative necessity of recognizing that 
there is a class of violent madmen who must be recognized as 
such, and restrained accordingly. 
HOSPITALS FOR CARE OF DANGEROUS INSANE RELATIONSHIP OF INSANITY TO CRIME 
343 
Without quibbling over hair-splitting technicalities, we are 
compelled to make certain practical definitions that we may 
have a working basis upon which to formulate our treatment of 
the dangerous insane. 
The criminal insane individual is a person whom the court 
has found to be insane at the time of trial or insane at the time 
he committed a criminal or dangerous act. He is an individual 
who is positively dangerous to the welfare of society because 
he is unable to control his conduct by reason of mental disease 
or lack of mental development. 
The insane criminal is an individual who has become insane 
or whose insanity was discovered after he was sent to prison, 
or an individual who becomes insane while serving sentence 
in prison. 
In the State of New York these two classes of patients have 
been separated, but the distinction made between them is largely 
an artificial one. The criminal insane are sent to the Matteawan 
State Hospital, and the insane criminals are sent to the Danne- 
mora State Hospital. Even though his arbitrary difference is 
made between these two groups, they are made of essentially the 
same types of persons. An individual who is classified as 
"criminal insane" may be one who has served several sentences 
in prison and while on parole or discharged from a penal insti- 
tution he commits a crime and is found to be insane at the time 
of trial, and because his history is unknown he is sent to a hos- 
pital for insane criminals. There is very little reason to separate 
these two classes since they are largely recruited from the same 
ranks of society and they require the same kind of treatment 
in the same sort of a hospital. 
If we examine carefully the records of hospitals for the crimi- 
nal insane, we will find that the majority of the inmates have 
been habitual criminals or individuals who have occupied all 
their lives a region that lies midway between sanity and insanity. 344 
MANUAL OF PSYCHIATRY 
The crimes of the insane and otherwise mentally defective pris- 
oners show an extremely high percentage of crimes against the 
person. I have found that the percentage for murder among 
the insane prisoners was three times as high among this class as 
among the inmates of the prison proper. For rape, sodomy and 
incest, it was one and one-half times greater. Among 169 insane 
prisoners, 43 were murderers and 16 were convicted of assault 
and battery with intent to murder; 25 of them were convicted 
of burglary, and every burglar is a potential murderer; 11 were 
convicted of rape and attempt to rape, and 4 were convicted 
of sodomy. 
The records of the Indiana State Prison of 2,365 consecutive 
admissions show the following interesting percentages: 
Per Cent 
Murder 5.2 
Rape, incest and sodomy 6.1 
Murder, manslaughter, rape 14.6 
Petit and grand larceny 53.2 
Of mentally defective prisoners: 
Per Cent 
Murder 16.6 
Rape, incest and sodomy 9.8 
Murder, manslaughter, rape 30.5 
Petit and grand larceny 37.7 
From these figures and tables we see that the majority of the 
crimes of the criminal insane and insane criminals is chiefly 
against the person. This fact is extremely pertinent and sug- 
gestive and indicates that there should be an indefinite seclusion 
of the individuals of these types. 
The insane criminals and criminal insane suffer with the 
same mental and nervous diseases as do the civil insane. I 
have noted, however, no matter what type their insanities may 
be, their symptoms are distinctly colored with delusions of 
persecution; 70 per cent of the patients at the Indiana State 
Hospital for Insane Criminals entertain some form of delusions RELATIONSHIP OF INSANITY TO CRIME 
345 
of a persecutory nature; some of the delusions are organized, 
and some are not. In my opinion this delusional state of mind 
is but a reflection of the whole course of their lives and indicates 
the deep-seated and inherent anti-social tendencies of their 
mental organizations. It explains to some degree the reason 
why their lives have always been in conflict with society. Their 
delusions, when organized, generally concern society, with whom 
they have always been at war, but the definite fabric of their 
false beliefs is woven about prosecuting attorneys, judges, 
prison officials and the medical officers of the prison. It is a 
very common practice for them to prepare long statements 
replete with legal terms setting forth their grievances and com- 
plaints against the world at large. Their daily conversations 
and behavior are filled with discussions and actions which relate 
to crime. Very often the more intelligent insane criminals 
attempt to play the part of attorneys and very often plead 
the case of some terminal dement to the hospital officials; even 
the games they play in the hospital grounds are very suggestive. 
Here in their sports they constantly refer to, and enact, scenes 
of their past lives. They play at having jails and prisons; they 
designate one another as policemen and detectives to catch 
make-believe criminals who are always made the central figures 
of their pastimes. 
In the hospitals for the criminal insane are to be found the 
sexual perverts of all descriptions. There were at this insti- 
tution thirty-five sexual perverts, and they constitute a very 
dangerous and troublesome class. It is necessary to keep them 
under the strictest observation to prevent them from committing 
homosexual acts. Quarreling and fighting among them is ex- 
tremely common, and this results from their love affairs and 
jealousies. They form attachments for each other, indulge in 
hugs and personal caresses, and slip into one another's beds if 
they have the slightest opportunity. The lovers are separated 346 
MANUAL OF PSYCHIATRY 
and placed in different wards in various parts of the hospital, 
and yet they send love notes, trinkets and favors to their sweet- 
hearts if they get an opportunity. They have even used salve 
boxes in which to send their semen to the objects of their 
affection. I have also noticed that the most violent love affairs 
occur between the white and colored men. The negroes are 
usually more aggressive and take the masculine part in their 
acts of sodomy. Some of these patients display absolutely no 
shame whatsoever about their perversions. Others, while appar- 
ently embarrassed, make splendid promises that they will never 
again commit homosexual acts, but of course their promises are 
broken the first time they have an opportunity. 
The insane criminals, whether they are still in prison or in 
hospitals for the criminal insane, are constantly manufacturing 
dangerous weapons. They display their ingenuity by converting 
the most harmless things into instruments of assault. Out of 
pieces of wood, spoons, toothbrushes, pens, pencils, stones and 
even thorns from plants, they make daggers. They steal socks, 
if they get an opportunity, and fill them with pebbles, sand, 
cinders, earth, pieces of soap, or anything else they can find, with 
which to make "blackjacks" to use in personal encounters. It 
is not an uncommon thing for them to make saws of clock 
springs. It is necessary to inspect the hospital furniture at very 
frequent intervals to see whether or not the reinforcing rods 
used in bracing chairs have been removed. In several instances 
the inspecting officers failed to find the missing rods. The thefts 
had been carefully concealed in a most novel manner. The 
patient, after removing the rod, molded a bolt head of putty 
and placed it at the site of the missing rod; wooden pins have 
been substituted for the same purpose. They make clubs by 
rolling newspapers and magazines tightly together, then soak 
them in water and wrap them firmly with bits of grass or string. RELATIONSHIP OF INSANITY TO CRIME 
347 
It is necessary to search their clothing at very frequent intervals 
for their home-made weapons. 
The criminal insane and the insane criminals do not belong 
in prisons or in civil hospitals for the insane; they interfere with 
all reformatory methods. They cannot be disciplined as are the 
normal prisoners; they create disturbances, are dangerous to the 
physical welfare of mentally normal prisoners and institutional 
officers. The presence of epileptics, mattoids, paranoids, para- 
noiacs, imbeciles and sexual perverts in our prison populations 
is a menace because of their dangerous tendencies and lack of 
capacity to adjust themselves to the environments and discipline 
of penal institutions. They threaten the lives of their fellow 
inmates and the institutional officers and not infrequently make 
dangerous and vicious assaults. These persons do not belong 
in penal institutions, which should be relieved of their presence 
whenever discovered. In our hospitals for the innocent insane 
are to be found dangerously violent persons, congenital, homo- 
sexual perverts and persons who are constitutionally immoral 
who do not belong in the civil hospitals, since they cannot be 
given the proper care and restraint in such institutions. 
It has been found by experience that it is very poor policy 
to place these dangerous insane in a separate department in 
ordinary civil hospitals. It has likewise been found faulty and 
ineffective to set apart for the care of this same class a certain 
part of the prison. Under the present state of affairs a hospital 
cannot be converted into a penal institution and neither can a 
penal institution be changed into a hospital. The purpose, 
organization and construction of a prison are diametrically 
opposed to those of a hospital for the insane. The spirit of 
these two institutions is entirely different. The official personnel 
of the hospital looks upon its inmates in an entirely different 
manner from the prison personnel, where the rules are far more 
strict, where there are definite tasks to be accomplished, and 348 
MANUAL OF PSYCHIATRY 
where certain definite punishments are inflicted for the violation 
of discipline. 
The question now arises, what is to be done with the criminal 
insane, since they neither belong in an ordinary hospital for the 
insane, nor a prison? The solution of the problem is to be found 
in a hospital for the criminal insane, and for this definite reason 
hospitals for the criminal insane and insane criminals were called 
into existence and developed to meet the specific problem of 
caring for persons who were at the same time insane and crimi- 
nal. Let us make a brief review of the history of the establish- 
ment of such institutions. The English Government was the 
first to initiate and construct a department for the care of this 
class of persons, and this was done by appropriating a special 
department at the Bedlam Asylum, in 1786, for the reception 
and treatment of criminal lunatics. Bethlehem Hospital was 
converted to this use in 1815; another institution of similar 
character was opened at Dundrum, Ireland, in 1850; another at 
Perth, Scotland, in 1859; and the famous Broadmoor Hospital 
was founded in 1863. One was established in our own country 
in New York State, in 1859, at Auburn. 
In France, after an unsatisfactory attempt to care for insane 
criminals at Bicetre, a separate wing was built for them at 
Gaillon Prison. The criminal insane in Holland were isolated 
in the hospital of Bosmalen. Germany established psychopathic 
wards in the prisons at Waldheim, Halle, Hamburg and Bruch- 
saal. 
There are two great fundamental reasons for the establishment 
of these institutions. The first, which is most important, is the 
social defense. Society must be defended against the dangerous 
and anti-social acts of all classes of individuals, whether they 
be criminal, insane, feebleminded, epileptic or otherwise mentally 
defective. The first great principle regulating our dealings with 
them must be that of social preservation. Our safety must be RELATIONSHIP OF INSANITY TO CRIME 
349 
equally insured against the robber who would take our money 
or our life, or the dangerous paranoiac who kills in a wild, 
homicidal mania, reacting to the systematized delusions of 
persecution, or the mentally irresponsible, erratic imbecile who 
may murder a helpless infant merely to gratify his depraved 
appetites. The second reason for the existence of hospitals for 
the criminal insane is born of humanitarian impulses; for we 
recognize that the criminal, the insane, the epileptic and the 
feebleminded owe their origin largely to the defects of the social 
organism. And since society is responsible for their existence, 
these defective, delinquent and dependent classes must share our 
humanity and our pity. 
Just as soon as psychopathic laboratories become an integral 
part of the legal machinery of our courts of justice, those indi- 
viduals who commit dangerous acts because of unsoundness of 
mind will be promptly discovered without running the whole 
gamut of criminal court procedure, as it is now practiced. When 
those individuals are discovered, they will be sent, without fur- 
ther loss of time, to hospitals for the criminal insane, and they 
will not be turned loose upon society because they are "not 
guilty of crime, because they are insane," and they will not 
be sent to ordinary prisons as normally minded felons, to be 
punished for acts which were purely symptomatic expressions of 
their unrecognized disorders. 
The psychopathic laboratory in the prison will at once dis- 
cover and classify the dangerous insane, who find their way 
into our prisons, because of the miscarriage of justice, and those 
prisoners who became insane while serving sentence, and are 
therefore dangerous to the rest of the prison inmates, will be 
transferred to hospitals for the criminal insane. Two very defi- 
nite conclusions are to be drawn from the study of criminal 
psychiatry: the modern psychiatrist, making due allowances 
for rhetorical differences, academic and legal finesse, recognizes 350 
MANUAL OF PSYCHIATRY 
that there is a distinct class of dangerous or criminal insane, 
who are to be discovered by psychopathic laboratories in the 
criminal courts, and in penal institutions. Since there does 
exist a dangerous mentally defective class, it becomes necessary 
for the states of the union to establish hospitals for the criminal 
insane, or to make equivalent provision for the care of these 
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MANUAL OF PSYCHIATRY 
38. ''Mental Medicine." Regis. 
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IV, Series 32. 
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52. "The Criminal." Havelock Ellis. 
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63. "Practical Manual of Insanity." Brower and Bannister. 
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68. "General Paresis." Kraepelin. 
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1 Chapter on "Crime and Insanity," excerpts from the two above papers, 
by permission of the J. B. Lippincott Co. INDEX 
Aboulia, 205, 228 
Abscess, brain, psychoses in, 104 
Absence in petit mal, 187 
Absurd statements, 277 
Aerophobia, 203 
Ageusia, 63 
Agoraphobia, 203 
Agraphia, 64 
Alcohol, psychoses due to, 106 
Alcoholic amnesia, 53 
coma, 46 
deterioration, 118 
course, 120 
diagnosis, 120 
etiology, 118 
pathology, 118 
prognosis, 120 
symptoms, 119 
treatment, 120 
dream states, 117 
epilepsy, 117 
hallucinosis, acute, 112 
course, 114 
diagnosis, 114 
etiology, 113 
prognosis, 114 
symptoms, 113 
treatment, 114 
chronic, 115 
insanity, relationship to crime, 
332 
paranoia, acute, 115 
course, 116 
diagnosis, 116 
prognosis, 116 
treatment, 116 
chronic, 117 
pseudo-paresis, 117 
Alcoholism, paresis and, differentia- 
tion, 93 
psychology of, 106 
Algolagnia, active, 221 
passive, 221 
Alternating insanity, 153 
Alzheimer's disease, symptoms, 76 
Amaurosis, 62 
Amaurotic family idiocy, 242 
American Psychiatric Association, 
classification of mental 
diseases as outlined by, 
33-35 
Amnesia, 53 
alcoholic, 53 
anterograde, 53 
retrograde, 53 
Anesthesia, moral, 224. See also 
Constitutional immoral- 
ity- 
Anger, morbid, 56 
Anorexia, 61 
Anosmia, 63 
Anterograde amnesia, 53 
Anxiety neuroses, 211 
diagnosis, 213 
etiology, 212 
hysteria and, differentiation, 213 
neurasthenia and, differentia- 
tion, 213 
pathology, 212 
prognosis, 213 
symptoms, 212 
treatment, 214 
Aphasia, 63 
Apoplectic coma, 48 
Apraxia, 64 
Aprosexia, 54 
Argyll-Robertson pupil, 62 
Arithmetical problems, 278 
Arsenical poisoning, psychoses due 
to, 128 
Arteriosclerotic brain atrophy, 
symptoms, 80 
dementia, paresis and, differentia- 
tion, 92 
relationship to crime, 330 
psychoses, symptoms, diagnostic 
grouping, 255 
Astasia-abasia, 205 
Asterognosis, 63 
Astraphobia, 203 
Atasia abasia, 24 
Ataxia, mental, 24 
Atrophy of brain, arteriosclerotic, 
symptoms, 80 
353 354 
INDEX 
Atropin poisoning, psychoses due 
to, 128 
Attention tests, 280 
Attitude, 269 
stereotypy of, 58 
Babinski reflex, 65 
Babinski's theory of hysteria, 195 
Behavior, 22 
Behavioristic psychology, 22 
Belladonna poisoning, psychoses due 
to, 128 
Bestiality, 222 
Bibliography, 351 
Binet-Simon tests, 285 
method of applying, 286 
Blindness, 62 
Blocking of thought, 55 
Blood in paresis, 84 
Born criminal, 229 
Bradycardia, 61 
Brain abscess, psychoses in, 104 
atrophy, arteriosclerotic, symp- 
toms, 80 
diseases, psychoses in, 102 
treatment, 105 
tumor, neurasthenia and, differ- 
entiation, 210 
psychoses in, 102 
Bromide poisoning, psychoses due 
to, 128 
Bulimia, 61 
Cannabis indica poisoning, psy- 
choses due to, 128 
Carbonic acid gas poisoning, psy- 
choses due to, 128 
Cardio-renal disease, psychoses in, 
135 
Catatonic type of dementia prsecox, 
168 
Catch questions, 276 
Cathartics, use of, 304 
Causes of mental disorders, 37 
exciting, 41 
pathological, 41 
physiological, 41 
predisposing, 37 
psychic, 41 
surgical, 42 
toxic, 42 
traumatic, 42 
Cephalalgia, 65 
Cerebral embolism, psychoses in, 
103 
hemorrhage, psychoses in, 103 
paresis and, differentiation, 91 
syphilis, crime and, 330 
thrombosis, psychoses in, 103 
Cerebrospinal fluid in paresis, 84 
Children's average psychological 
level, 288. See also Psy- 
chological level of chil- 
dren. 
Chloroform intoxication, psychoses 
due to, 128 
Chorea, Huntington's, psychoses in, 
104 
Sydenham's, psychoses in, 105 
Circumstantiality, 53 
Civil conditions, relation of, to 
insanity, 40 
Civilization, relation of, to insan- 
ity, 41 
Classification of mental disorders, 
27 
Claustrophobia, 203 
Climate, relation of, to insanity, 40 
Clinical classification of mental dis- 
orders, 31 
Clouding of consciousness, 44 
Cocaine bug, 122 
Cocainism, 121 
course, 123 
etiology, 121 
pathology, 122 
prognosis, 123 
relationship to crime, 338 
symptoms, 122 
treatment, 123 
Collapse delirium, symptoms, 133 
Coma, 45 
alcoholic, 46 
apoplectic, 48 
diabetic, 50 
epileptic, 47 
hysterical, 47 
opium, 46 
paretic, 49 
uremic, 48 
Comatose states, 45 
Commitment to hospitals for in- 
sane, 299 
Complaint, spontaneous, 271 
Complex, 58 
Friedman's, 69 
submerged, 59 
Compulsions, 57 
Concentric constriction of visual 
field, 63 
Conceptions, 18 
ethical, 280 
Confusion, 45 
Consciousness, clouding of, 44 
definition of, 18 
disorders of, 44 
Constipation, treatment, 304' INDEX 
355 
Constitution, post traumatic symp- 
toms, 69 
Constitutional depression, states of, 
217 
treatment, 218 
excitement, states of, 218 
treatment, 219 
immorality, 224 
diagnosis, 231 
due to defect in emotional 
sphere, 229 
in intellectual sphere, 227 
in volitional sphere, 227 
etiology, 226 
mechanism, 226 
symptoms, 226 
treatment, 232 
inferiority, psychoses with, 215 
Convulsions, 64, 268 
Coordination tests, 267 
Cortical devastation, senile, symp- 
toms, 80 
Cretinism, psychoses in, 137, 138 
Crime, relationship of alcoholic 
insanity to, 332 
of arteriosclerotic dementia to, 
330 
of cocainism to, 338 
of dementia prsecox to, 319 
of drug psychoses to, 332 
of epilepsy to, 314 
of feeble-mindedness to, 339 
of general paresis to, 320 
of hysterical insanity to, 323 
of imbecility to, 339 
of insanity to, 313 
of manic-depressive insanity to, 
322 
of morphinic insanity to, 337 
of paranoia to, 318 
of paranoid states to, 318 
of puerperal insanity to, 327 
of senile psychoses to, 329 
of syphilitic insanity to, 330 
Criminal, born, 229 
insane, hospitals for, 342 
Definition of mental disorders, 27 
questions in, 278 
Delirious states, 45 
Delirium, collapse, treatment, 133 
exhaustion, 133 
course, 134 
diagnosis, 134 
etiology, 133 
pathology, 133 
prognosis, 134 
symptoms, 133 
treatment, 134 
Delirium, febrile, 132 
post traumatic, symptoms, 68 
postfebrile, 132 
prefebrile, 131 
treatment, 303 
tremens, 109 
etiology, 109 
pathology, 109 
symptoms, 110 
treatment, 111 
uremic, 135 
diagnosis of, 136 
prognosis, 136 
treatment, 136 
with infectious diseases, 131 
Delusions, 51, 273 
classification of, 52 
Dementia, arteriosclerotic, paresis 
and, differentiation, 92 
relationship to crime, 330 
prcecox, 24, 162 
catatonic type, 168 
definition, 162 
diagnosis, 174 
etiology, 162 
hebephrenic type, 166 
hysteria and, differentiation, 199 
mixed type, 174 
neurasthenia and, differentia- 
tion, 210 
paranoid type, 171 
pathology, 163 
psychology, 174 
relationship to crime, 319 
simple type, 165 
symptoms, 164 
diagnostic grouping, 248 
traumatic psychoses and, differ- 
entiation, 70 
treatment, 175 
medical, 176 
prophylactic, 175 
senile, paresis and, differentia- 
tion, 92 
Depersonalization, 54 
Depression, constitutional, states of, 
217 
treatment, 218 
marked, 56 
Depressive mania, symptoms, 152 
with flight of ideas, symptoms, 
152 
Deterioration, emotional, 56 
Diabetes, psychoses in, 138 
Diabetic coma, 50 
Diagnostic groupings of symptoms 
of psychoses, 248 
Diagrammatic explanation of mind, 
25 356 
INDEX 
Dipsomania, 120 
treatment, 121 
Disassociated state, 59 
Disposition, mercurial, 56 
Dizziness, 66 
Drawing test, 279 
Dread neuroses, 211 
Dream states, 50 
alcoholic, 117 
Drug psychoses, relationship to 
crime, 332 
Drugs and insanity, 301 
psychoses due to, 106, 127 
treatment, 129 
Ductless glands, diseases of, psy- 
choses in, 136 
Dysarthria, 63 
Dysfunction of thyroid gland, psy- 
choses in, 138 
Dysgrahia, 64 
Echolalia, 57 
Echopraxia, 57 
Education, relation of, to insanity, 
41 
Elation, pathological, 56 
Electrical reactions, 268 
Embolism, cerebral, psychoses in, 
103 
Emotion', disorders of, 56 
Emotional deterioration, 56 
poverty, 56 
status, 271 
Encephalitis, lethargic, psychoses 
in, 143 
symptoms, 144 
treatments, 145 
subcortical, symptoms, 80 
Endocrine therapy, 309 
Enuresis, 65 
Epilepsy, alcoholic, 117 
Jacksonian, 188 
psychic, 189 
psychical, 317 
relationship to crime, 314 
syphilitic, 99 
Epileptic coma, 47 
idiocy, 242 
psychoses, 185 
definition, 185 
diagnosis, 190 
differential, 190 
etiology, 185 
grand mal, 187 
intraparoxysmal symptoms, 189 
nature, 190 
paroxysmal symptoms, 187 
pathology, 186 
petit mal, 187 
Epileptic phychoses, post paroxys- 
mal symptoms, 188 
preparoxysmal symptoms, 186 
prognosis, 191 
psychology, 190 
symptoms, 186 
treatment, 191 
Eroticism, 220 
Ethical conceptions, 280 
Etiological classification of mental 
disorders, 30 
Eugenics and heredity, 300 
Exaggerated impulses, 228 
Examination, absurd statements, 
277 
arithmetical problems, 278 
attention tests, 280 
attitude, 269 
catch questions, 276 
delusions, 273 
drawing test, 279 
emotional status, 271 
ethical conceptions, 280 
family history, 260 
forward and backward association 
test, 279 
free word association test, 281 
hallucinations, 272 
history of present illness, 262 
insight, 274 
interpretation of pictures, 278 
of proverbs, 279 
limited word association test, 281 
manner, 269 
memory, 274 
mental, 268 
mental make-up, 269 
methods of, 260 
motor reactions, 278 
neurological, 264 
orientation, 274 
personal history, 261 
physical, 263 
problems, 277 
psychoanalysis, 280 
questions in definition, 278 
sentence building tests, 279 
spontaneous complaint, 271 
stories, 275 
stream of mental activity, 271 
supplying words in sentences, 279 
syllogisms, 280 
tapping tests, 280 
Excitement, constitutional, states 
of, 218 
treatment, 219 
Exciting causes of mental disorders, 
41 INDEX 
357 
Exhaustion delirium, 133 
course, 134 
diagnosis, 134 
etiology, 133 
pathology, 133 
prognosis, 134 
symptoms, 133 
treatment, 134 
Exhibitionism, 222 
Exophthalmic goitre, psychoses in, 
137 
Explosive will, 228 
Extramural treatment, 302 
Facial muscles, tests for, 266 
Family history, 260 
idiocy, amaurotic, 242 
Fear, 55 
Febrile delirium, 132 
Feeble-minded prisoners, 341 
Feeble-mindedness, 238 
definition, 239 
diagnosis, 246 
etiology, 239 
pathology, 240 
prognosis, 246 
relationship to crime, 339 
symptoms, 245 
treatment, 246 
Feeding, forced, 306 
Fetichism, 222 
Flexibilitas cerea, 57 
Flexibilities cerea, 169 
Flight of ideas, 53 
Focal infections, treatment, 308 
Forced feeding, 306 
Formications, 65 
Forward and backward association 
test, 279 
Free word association method, 281 
Freud's theory of hysteria, 195 
Friedman's complex,, 69 
Ganser's symptom, 54 
Gastro-intestinal disorders, psy- 
choses in, 139 
tract, diseases of, treatment, 308 
Genital organs, diseases of, treat- 
ment, 309 
Gliosis pervascular, symptoms, 80 
Goitre, exophthalmic, psychoses in, 
137 
Gout, psychoses in, 138 
Grand mal, 187 
Hallucinations, 51, 272 
somatic, 273 
tactile, 273 
Hallucinations, varieties of, 51 
visual, 272 
Hallucinatory confusion, acute, 133 
Hallucinosis, alcoholic, acute, 112 
course, 114 
diagnosis, 114 
etiology, 113 
prognosis, 114 
symptoms, 113 
treatment, 114 
chronic, 115 
Handwriting, 267 
Headache, 65 
Hearing, tests for, 266 
Heart, diseases of, 61 
Hebephrenic type of dementia prae- 
cox, 166 
Hemorrhage, cerebral, psychoses in, 
103 
Heredity and eugenics, 300 
relation to insanity, 37 
History of present illness, 262 
Homosexuality, 221 
Hospitals for care of dangerous in- 
sane, 342 
psychopathic, 299 
commitment to, 299 
Huntington's chorea, psychoses in, 
104 
Hydrotherapy, 304 
Hyperamnesia, 53 
Hyperprosexia, 54 
Hyperthyroidism, psychoses in, 137 
Hypomania, symptoms, 150 
Hypothyroidism, psychoses in, 137 
Hysteria, 193 
anxiety neuroses and, differentia- 
tion, 213 
definition, 193 
dementia prsecox and, differenti- 
ation, 199 
diagnosis, 199 
etiology, 193 
motor symptoms, 198 
neurasthenia and, differentiation, 
209 
prognosis, 200 
psychic symptoms, 196 
sensory symptoms, 197 
symptoms, 196 
diagnostic grouping, 257 
traumatic psychoses and, differen- 
tiation, 70 
treatment, 200 
Hysterical coma, 47 
insanity, relationship to crime, 
323 
Hystero-epilepsy, 200 INDEX 
358 
Ideas, flight of, 53 
Ideation, incoherent, 53 
Idiocy, 238 
amaurotic family, 242 
definition, 238 
diagnosis, 246 
epileptic, 242 
etiology, 239 
inflammatory, 243 
microcephalic, 242 
Mongolian, 243 
paralytic, 242 
pathology, 240 
physical symptoms, 241 
prognosis, 246 
sclerotic, 243 
sensorial, 243 
symptoms, 241 
syphilitic, 243 
thyroigenous, 242 
traumatic, 243 
treatment, 246 
Illness, present, history of, 262 
Illusions, 51 
Imbecility, 238 
definition, 239 
diagnosis, 246 
etiology, 239 
mental symptoms, 244 
mild type, 244 
moral, 224. See also Constitu- 
tional immorality. 
pathology, 240 
prognosis, 246 
pronounced type, 244 
relationship to crime, 339 
savant, 244 
symptoms, 244 
treatment, 246 
Immorality, constitutional, 226. 
See also Constitutional 
immorality. 
Impulses, exaggerated, 228 
Impulsions, 57 
Impulsive states, 219 
Incoherent ideation, 53 
Incontinence of urine, 65 
Infections, focal, treatment, 308 
Inflammatory idiocy, 243 
Influenza, psychoses in, 143 
Infectious diseases, delirium with, 
131 
Inherited predisposition to insan- 
ity, 37 
Insanity, 27 
alcoholic, relationship to crime, 
332 
alternating, 153 
Insanity, definition of, 29 
legal, 28 
manic depressive, paresis and, dif- 
ferentiation, 92 
traumatic psychoses and, dif- 
ferentiation, 70 
masturbatic, 221 
medical, 28 
moral, 224. See also Constitu- 
tional immorality. 
morphinic, relationship to crime, 
337 
relationship to crime, 313 
Insight, 274 
Insomnia, treatment, 305 
Intellection, disorders of, 44 
Intelligence tests, Binet-Simon, 285 
Internal organs, diseases of, 61 
Intoxication, pathological, 108 
treatment, 109 
Intramural treatment, 303 
Involutional melancholia, 156. See 
also Melancholia, invo- 
lutional. 
Iridoplegia, 62 
Jacksonian epilepsy, 188 
Janet's theory of hysteria, 195 
Juvenile paresis, 83 
Kleptomania, 204 
Korsakow's psychosis, 111 
treatment, 111 
Lactation, psychoses in, 141, 142 
Lead poisoning, psychoses due to, 
127 
Legal insanity, 28 
Lethargic encephalitis, psychoses in, 
143 
symptoms, 144 
treatment, 145 
Lethargy, 50 
Liars, pathological, 230 
Limited word association test, 281 
Luminal in epilepsy, 192 
Malaria, psychoses in, 140 
Malingering, 233 
Mania, acute, symptoms, 151 
depressive, symptoms, 152 
with flight of ideas, symptoms, 
152 
exhaustive, symptoms, 152 
hyperacute, symptoms, 152 
recurrent, symptoms, 152 
stuporous, symptoms, 152 
unproductive, symptoms, 152 INDEX 
359 
Manic-depressive insanity, paresis 
and, differentiation, 92 
traumatic psychoses and, dif- 
ferentiation, 70 
psychoses, 146 
acute mania, symptoms, 151 
melancholia, symptoms, 148 
alternating insanity, 153 
course, 154 
definition, 146 
depressive mania, symptoms, 
152 
with flight of ideas, symp- 
toms, 152 
phase, symptoms, 147 
treatment, 154 
diagnosis, 153 
etiology, 146 
exhaustive mania, symptoms, 
152 
hyperacute mania, symptoms, 
152 
hypomania, 150 
manic phase, symptoms, 149 
treatment, 155 
neurasthenia and, differentia- 
tion, 210 
pathology, 147 
prognosis, 154 
psychology, 153 
recurrent mania, symptoms, 152 
melancholia, 153 
relationship to crime, 322 
simple depression, symptoms, 
148 
stuporous mania, symptoms, 
152 
melancholia, symptoms, 149 
symptoms, 147 
diagnostic grouping, 251 
treatment, 154 
unproductive mania, symp- 
toms, 152 
states due to syphilis, 99 
Mankopf's symptom, 70 
Manner, 269 
Masochism, 221 
Masturbatic insanity, 221 
Masturbation, 220 
Mattoids, 231 
Medical insanity, 28 
Medication, tonic, 306 
Melancholia, acute, symptoms, 148 
involutional, anxiety type, 158 
apathetic type, 159 
course, 160' 
definition, 156 
Melancholia, involutional, delusions 
of, 159 
diagnosis, 159 
etiology, 156 
pathology, 157 
pre-senile type, 158 
prognosis, 160 
psychology, 160 
self-accusatory type, 158 
symptoms, 157 
diagnostic grouping, 252 
treatment, 160 
recurrent, 153 
stuporous, symptoms, 149 
Memory, 274 
defect of, 52 
definition of, 18 
loss of, 53 
Mendelian hypothesis, 37 
Meningitis, psychoses in, 103 
Mental activity, stream of, 271 
disorders, causes of, 37 
exciting, 41 
predisposing, 37 
psychic, 41 
civil conditions and, 40 
civilization and, 41 
classification of, 27 
climate and, 40 
clinical classification, 31 
definition of, 27 
education and, 41 
etiological classification, 30 
heredity and, 37 
inherited predisposition to, 37 
pathological causes, 41 
classification, 31 
physiological causes, 41 
psychological classification, 30 
surgical causes, 42 
toxic causes, 42 
traumatic causes, 42 
enfeeblement, post traumatic, 
symptoms, 69 
syphilitic, 98 
examination, 268 
make-up, 269 
criminalistic type, 270 
depressive type, 269 
erotic type, 270 
fault-finding type, 270 
hysterical type, 270 
irritable type, 270 
manic type, 269 
paranoid type, 270 
seclusive type, 269 
unstable type, 270 
Mercurial disposition, 56 
Meteorism, 61 INDEX 
360 
Methods of examination, 260 
Microcephalic idiocy, 242 
Mind, definition of, 17 
diagrammatic explanation, 25 
functions of, 19 
Misophobia, 203 
Mongolian idiocy, 243 
Moral anesthesia, 224. See also 
Constitutional immoral- 
ity. 
imbecility, 224. See also Con- 
stitutional immorality. 
insanity, 224. See also Constitu- 
tional immorality. 
Morbid anger, 56 
Moron, definition, 238 
Morphinic insanity, relationship to 
crime, 337 
Morphinism, 123 
course, 125 
diagnosis, 125 
etiology, 123 
pathology, 124 
prognosis, 125 
symptoms, 124, 125 
treatment, 126 
Motor reactions, 278 
speech, tests for, 267 
Movement, stereotypy of, 57 
Multiple personality, 54 
sclerosis, psychoses in, 104 
Myxedema, psychoses in, 137 
Narcissism, 222 
Necrophilia, 222 
Negativism, 57 
Nervous diseases, psychoses in, 102 
treatment, 105 
Neurasthenia, 206 
anxiety neuroses and, differentia- 
tion, 213 
brain tumor and, differentation, 
210 
cerebral type, 207 
circulatory type, 208 
course, 209 
definition, 206 
dementia praecox and, differentia- 
tion, 210 
diagnosis, 209 
etiology, 206 
gastro-intestinal type, 208 
genital type, 208 
hysteria and, differentiation, 209 
manic-depressive insanity and, 
differentiation, 210 
paresis and, differentiation, 92, 
209 
pathology, 207 
Neurasthenia, prognosis, 210 
spinal type, 208 
symptoms, 207 
diagnostic grouping, 256 
traumatic, 211 
treatment, 210 
Neurological examination, 264 
symptoms, 62 
Neuroses, 193 
anxiety, 211 
diagnosis, 213 
etiology, 212 
hysteria and, differentiation, 213 
neurasthenia and, differentia- 
tion, 213 
pathology, 212 
prognosis, 213 
symptoms, 212 
treatment, 214 
dread, 211 
Numbness, 65 
Nutrition, state of, 60 
Nymphomania, 204, 220 
Obsessions, 55 
varieties of, 55 
Occupational therapy, 312 
Onomatomania, 201 
Opium coma, 46 
Organic reflexes, tests for, 267 
sensations, 268 
Organo-therapy, 309 
Orientation, 50, 274 
personal, 50 
spatial, 50 
temporal, 51 
Palate, tests for, 267 
Paragraphia, 64 
Paralexia, 64 
Paralysis agitans, psychoses in, 103 
of thoughts, 55 
Paralytic idiocy, 242 
Paramnesia, 53 
Paranoia, 178 
alcoholic, acute, 115 
course, 116 
diagnosis, 116 
prognosis, 116 
treatment, 116 
chronic, 117 
definition, 178 
diagnosis, 183 
etiology, 178 
pathology, 179 
prognosis, 184 
relationship to crime, 318 INDEX 
361 
Paranoia, stage of hypochondriasis, 
179 
of persecution, 181 
of subjective analysis, 179 
of systematized delusions, 181 
of transformation of the person- 
ality, 182 
symptoms, 179 
diagnostic grouping, 250 
syphilitic, 98 
occurring in absence of tabes 
dorsalis, 98 
treatment, 184 
Paranoid states, 178, 183 
relationship to crime, 318 
type of dementia praecox, 171 
Paraphrenia, 172 
Paresis, 23, 83 
agitated form, symptoms, 89 
alcoholism and, differentiation, 93 
arteriosclerotic dementia and, dif- 
ferentiation, 92 
blood in, 84 
cerebral syphilis and, differentia- 
tion, 91 
cerebrospinal fluid in, 84 
course, 93 
definition, 83 
demented form, symptoms, 88 
depressed form, symptoms, 90 
diagnosis, 91 
etiology, 83 
expansive form, symptoms, 88 
general relationship to crime, 320 
symptoms, diagnostic grouping, 
253 
juvenile, 83 
manic depressive insanity and 
differentiation, 92 
neurasthenia and, differentiation, 
92, 209 
neurological symptoms, 86 
pathology, 84 
prognosis, 94 
pseudo, syphilitic, 98 
psychological analysis in, 93 
psychoses with cerebral arterio- 
sclerosis and, differentia- 
tion, 81 
senile dementia and, differentia- 
tion, 92 
symptoms, 85 
traumatic psychoses and, differen- 
tiation, 70 
treatment, 94 
Wassermann reaction in, 84, 85 
Paretic coma, 49 
Parturition, psychoses in, 141, 142 
Patellar reflex, 65 
Pathological causes of mental dis- 
orders, 41 
classification of mental disorders, 
35 
elation, 56 
intoxication, 108 
treatment, 109 
liars, 230 
swindlers, 230 
Pellagra, psychoses in, 139 
Perception, definition of, 18 
Perivascular gliosis, symptoms, 80 
Perseveration, 58 
Personal history, 261 
orientation, 50 
Personality, disorders of, 54 
multiple, 54 
Perverted sexual instincts, 219 
Petit mal, 187 
Physical examination, 263 
Physiological causes of mental dis- 
orders, 41 
Pictures, interpretation of, 278 
Pithiatism, 195 
Poisoning, arsenical, psychoses due 
to, 128 
atropin, psychoses due to, 128 
belladonna, psychoses due to, 128 
bromide, psychoses due to, 128 
cannabis indica, psychoses due to, 
128 
carbonic acid gas, psychoses due 
to, 128 
lead, psychoses due to, 127 
santonin, psychoses due to, 128 
veronal, psychoses due to, 128 
Postfebrile delirium, 132 
Post-infectious psychoses, 132 
Post-traumatic constitution, symp- 
toms, 69 
delirium, symptoms, 68 
mental enfeeblement, symptoms, 
69 
Poverty, emotional, 56 
Prefebrile delirium, 131 
Pregnancy, psychoses in, 141 
Presbyophrenic type of senile psy- 
choses, symptoms, 75 
Preventive treatment, 298 
Problems, 277 
arithmetical, 278 
Proverbs, interpretation of, 279 
Pseudo-paresis, alcoholic, 117 
syphilitic, 98 
Psychasthenia, 202 
definition, 202 
diagnosis, 205 
emotional obsessions, 203 
etiology, 202 362 
INDEX 
Psychasthenia, imperative ideas, 204 
intellectual obsessions, 203 
morbid desires, 204 
pathology, 202 
prognosis, 205 
symptoms, 202 
treatment, 205 
volitional obsessions, 204 
Psychic causes of mental disorders, 
41 
epilepsy, 189 
Psychical epilepsy, 317 
Psychoanalysis, 280, 311 
Psychogenetic states due to morbid 
fear of syphilis, 99 
Psychological analysis in paresis, 93 
of psychoses with cerebral ar- 
teriosclerosis, 81 
of senile psychoses, 77 
of traumatic psychoses, 71 
classification of mental disorders, 
30 
level of adults, average normal, 
296 
of children at eight years of 
age, average normal, 292 
at five years of age, average 
normal, 289 
at four years of age, average 
normal, 288 
at fourteen years of age, 
average normal, 295 
at nine years of age, average 
normal, 292 
at seven years of age, average 
normal, 291 
at six years of age, average 
normal, 290 
at ten years of age, average 
normal, 293 
at three years of age, average 
normal, 288 
at twelve years of age, aver- 
age normal, 294 
of superior adults, average, 297 
Psychomotor activity decreased, 57 
increased, 57 
Psychoneuroses, 193 
Psychopathic hospitals, 299 
commitment to, 299 
states due to inherited syphilis, 99 
Psychoses, arteriosclerotic, symp- 
toms, diagnostic group- 
ing, 255 
due to alcohol, 106 
to arsenical poisoning, 106 
to atropin poisoning, 128 
to belladonna poisoning, 128 
to bromide poisoning, 128 
Psychoses due to cannabis indica 
poisoning, 128 
to carbonic acid gas poisoning, 
128 
to chloroform intoxication, 128 
to drugs, 106, 127 
treatment, 129 
to exogenous toxins, 106 
to lead poisoning, 127 
to santonin poisoning, 128 
to veronal poisoning, 128 
epileptic, 185. See also Epileptic 
psychoses. 
in brain abscess, 104 
tumor, 102 
in cardio-renal disease, 135 
in cerebral embolism, 103 
hemorrhage, 103 
thrombosis, 103 
in cretinism, 137, 138 
in diabetes, 138 
in diseases of ductless glands, 136 
in dysfunction of thyroid gland, 
138 
in exophthalmic goiter, 137 
in gastro-intestinal disorders, 139 
in gout, 138 
in Huntington's chorea, 104 
in hyperthyroidism, 137 
in hypothyroidism, 137 
in influenza, 143 
in lactation, 141, 142 
in lethargic encephalitis, 143 
in malaria, 140 
in meningitis, 103 
in multiple sclerosis, 104 
in myxedema, 137 
in paralysis agitans, 103 
in parturition, 141, 142 
in pellagra, 139 
in pregnancy, 141 
in puerperium, 141, 142 
in rheumatic fever, 140 
in Sydenham's chorea, 105 
in tabes dorsalis, 104 
manic-depressive, 146. See also 
Manic-depressive psy- 
choses. 
post-infectious, 132 
senile, 72. See also Senile psy- 
choses. 
symptoms, diagnostic groupings, 
248 
syphilitic, psychoses with cerebral 
arteriosclerosis and, dif- 
ferentiation, 81 INDEX 
363 
Psychoses, traumatic, 67 
definition, 67 
dementia praecox and, differen- 
tiation, 70 
differential diagnosis, 70 
etiology, 67 
hysteria and, differentiation, 70 
manic depressive insanity and, 
differentiation, 70 
paresis and, differentiation, 70 
pathology, 67 
prognosis, 71 
psychological analysis, 71 
symptoms, 68 
treatment, 71 
with brain diseases, 102 
treatment, 105 
with cerebral arteriosclerosis, 79 
definition, 79 
diagnosis, 81 
etiology, 79 
paresis and, differentiation, 
81 
pathology, 79 
prognosis, 81 
psychological analysis, 81 
senile psychoses and, dif- 
ferentiation, 81 
symptoms, 80 
syphilitic psychoses and, 
differentiation, 81 
treatment, 82 
syphilis, 95 
definition, 95 
diagnosis, 99 
endarteritic type, 95 
etiology, 96 
gummatous type, 95 
meningitic type, 95 
mixed type, 96 
pathology, 96 
primary stage, symptoms, 96 
secondary stage, symptoms, 
97 
symptoms, 96 
tertiary and quaternary 
states, symptoms, 97 
transient states of confusion 
attended by hallucina- 
tions, 99 
treatment, 100 
with constitutional inferiority, 
215 
etiology, 215 
pathology, 216 
symptoms, 216 
with mental deficiency, 238 
with nervous diseases, 102 
treatment, 105 
Psychoses with somatic diseases, 
130 
etiology, 130 
pathology, 131 
symptoms, 131 
Psychosis, Korsakow's, 111 
treatment, 111 
Psychotherapy, 311 
Psychotic states associated with 
syphilitic disease of heart 
or aorta, 99 
Puerperal insanity, relationship to 
crime, 327 
Puerperium, psychoses in, 141, 142 
Pulse, 61 
Pupil, Argyll-Robertson, 62 
rigidity of, 62 
Pupillary disturbance, 62 
Pyromania, 204 
Querulants, 231 
Questions, catch, 276 
Reasoning, 19 
Recreational therapy, 312 
Recurrent mania, 152 
melancholia, 153 
Reflex, Babinski, 65 
patellar, 65 
Reflexes, 64 
deep, tests for, 267 
organic, tests for, 267 
superficial, 64 
tests for, 267 
Repression, 23 
Respiration, 61 
Retardation of thought, 55 
executive, 55 
initial, 55 
Retrograde amnesia, 53 
Rheumatic fever, psychoses in, 140 
Rigidity of pupil, 62 
Sadism, 221 
Santonin poisoning, psychoses due 
to, 128 
Satyriasis, 205, 220 
Savant imbecility, 244 
Schizophrenia, 162. See also De- 
mentia prcecox. 
Sclerosis, multiple, psychoses in, 104 
Sclerotic idiocy, 243 
Senile cortical devastation, symp- 
toms, 80 
dementia, paresis and, differentia- 
tion, 92 364 
INDEX 
Senile psychoses, 72 
definition, 72 
delirious and confused types, 
symptoms, 76 
depressed and agitated types, 
symptoms, 76 
diagnosis, 77 
differential, 77 
etiology, 72 
paranoid type, symptoms, 76 
pathology, 73 
physical symptoms, 75 
presbyophrenic type, symptoms, 
75 
presenile type, symptoms, 76 
prognosis, 78 
psychological analysis, 77 
psychoses with cerebral arterio- 
sclerosis and, differentia- 
tion, 81 
relationship to crime, 329 
simple deterioration, symptoms, 
75 
symptoms, 73 
diagnostic grouping, 254 
treatment, 78 
Sensation, definition of, 18 
Sensations, organic, 268 
subjective, 268 
Sensibility, disturbances of, 66 
Sensorial idiocy, 243 
Sensory functions, tests for, 268 
Sentence building tests, 279 
supplying words in, 279 
Serum therapy, 309 
Sexual abnormalities, 219 
diagnosis, 224 
etiology, 220 
prognosis, 224 
qualitative, 220 
quantitative, 220 
symptoms, 222 
treatment, 224 
hyperesthesia, 220 
Simulation, 233 
Sinuses, diseases of, treatment, 309 
Sleep, 268, 305 
Smell, loss of sense of, 63 
tests for, 265 
Sollier's theory of hysteria, 195 
Somatic diseases, psychoses with, 
130 
etiology, 130 
pathology, 131 
symptoms, 131 
hallucinations, 273 
symptoms, 60 
Somnolence, states of, 45 
Spasms, 64 
Spatial orientation, 50 
Speech, disorders of, 63 
motor, tests for, 267 
stereotypy of, 57 
Sphincteric control, 65 
Spontaneous complaint, 271 
Stereotypy, 57 
of attitude, 58 
of movement, 57 
of speech, 57 
Stethoscope test, 266 
Stories, 275 
Stuporous mania, symptoms, 152 
melancholia, symptoms, 149 
states, 45 
Subcortical encephalitis, symptoms, 
80 
Subjective sensations, 268 
Submerged complex, 59 
Suggestibility, 57 
Surgical causes of mental dis- 
orders, 42 
conditions, treatment, 308 
Swindlers, pathological, 230 
Sydenham's chorea, psychoses in, 
105 
Syllogisms, 280 
Symptoms, 44 
neurological, 62 
of psychoses, diagnostic group- 
ings, 248 
somatic, 60 
Syncope, 50 
Syphilis and insanity, 301 
cerebral, crime and, 330 
paresis and, differentiation, 91 
inherited, psychopathic states due 
to, 99 
morbid fear of, psychogenetic 
states due to, 99 
Syphilitic epilepsy, 99 
idiocy, 243 
insanity, relationship to crime, 
330 
mental enfeeblement, 98 
paranoia, 98 
occurring in absence of tabes 
dorsalis, 98 
pseudo paresis, 98 
psychoses, diagnosis, 99 
endarteritic type, 95 
etiology, 96 
gummatous type, 95 
meningitic type, 95 
mixed type, 96 
pathology, 96 
primary stage, symptoms, 96 INDEX 
365 
Syphilitic psychoses, psychoses with 
cerebral arteriosclerosis 
and, differentiation, 81 
secondary stage, symptoms, 97 
symptoms, 96 
tertiary and quaternary states, 
symptoms, 97 
transient states of confusion at- 
tended by hallucinations, 
99 
treatment, 100 
Tabes dorsalis, psychoses in, 104 
Tactile hallucinations, 273 
Tapping test, 280 
Taste, loss of sense of, 63 
tests for, 266 
Temperature, changes of, 62 
Temporal orientation, 51 
Tests, attention, 280 
Binet-Simon, 285 
method of applying, 286 
coordination, 267 
drawing, 279 
for deep reflexes, 267 
for facial muscles, 266 
for hearing, 266 
for motor speech, 267 
for palate, 267 
for reflexes, 267 
for sensory functions, 268 
for smell, 265 
for superficial reflexes, 267 
for taste, 266 
for visual fields, 265, 266 
forward and backward associa- 
tion, 279 
free word association, 281 
intelligence, Binet-Simon, 285 
limited word association, 281 
sentence building, 279 
syllogisms, 280 
tapping, 280 
Thought, blocking of, 55 
paralysis of, 55 
retardation of, 55 
executive, 55 
initial, 55 
Thrombosis, cerebral, psychoses in, 
103 
Thyroid gland, dysfunction of, psy- 
choses in, 138 
Thyroigenous idiocy, 242 
Tics, 268 
Tinglings, 65 
Tonic medication, 306 
Toxic causes of mental disorders, 42 
Toxins, exogenous, psychoses due 
to, 106 
Traumatic causes of mental dis- 
orders, 42 
idiocy, 243 
neurasthenia, 211 
psychoses, 67 
definition, 67 
dementia praecox and, differ- 
entiation, 70 
differential diagnosis, 70 
etiology, 67 
hysteria and, differentiation, 70 
manic depressive insanity and, 
differentiation, 70 
paresis and, differentiation, 70 
pathology, 67 
prognosis, 71 
psychological analysis, 71 
symptoms, 68 
treatment, 71 
Treatment, 298 
endocrine, 309 
extramural, 302 
intramural, 303 
occupational, 312 
prevention, 298 
recreational, 312 
serum, 309 
vaccine, 309 
Tremors, 64, 268 
Tuberculosis and insanity, 301 
Tumor, brain, neurasthenia and, 
differentiation, 210 
psychoses in, 102 
Uremic coma, 48 
delirium, 135 
diagnosis, 136 
prognosis, 136 
treatment, 136 
Urine, incontinence of, 65 
Vaccine therapy, 309 
Veronal poisoning, psychoses due 
to, 128 
Visual field, concentric constric- 
tion, 63 
fields, tests for, 265, 266 
hallucinations, 272 
Volition, disorders of, 57 
Vomiting, 61 
Wassermann reaction in paresis, 
84, 85 
Waxen flexibility, 169 
Will, arrest of, 228 
explosive, 228 
Writing, errors in, 64